a controlled trial without randomisation, a quasi experiments, or a failed randomisation

Type the text for '(iii) cohort studies'

Tags all referenced papers in the chapter

The adolescent community reinforcement approach
(ACRA) (Godley et al 2001a; Meyers & Smith 1995) is an
individualized ''behavioral'' (operant) approach that includes
#10 sessions with the adolescent and
#four sessions with caregivers.
This approach was based on community reinforcement approach procedures that had proven effective with adults. Based on NIAAA-funded research, ACRA’s premise is that learning alternative skills to cope with problems and changing environmental contingencies related to continued substance use will help reduce use.
Its goals are to
#change antecedent behaviors of the adolescent and
#increase parental behaviors that are supportive of their adolescent’s abstinence.
Because this is an individualized approach, one of its advantages is that it can be used in rural areas where group formation may actually delay or increase the cost of treatment.
''futher details from [[Randall and Cunningham 2003]]... on the addition of CRA as a wraparound to MST to boost its effectiveness in SUD:''
...enhancements (To MST) were based on the work of Higgins and Budney et al. (Budney &
Higgins, 1998; Budney, Higgins, Radonovich, & Novy, 2000; Higgins & Budney, 1993;
Higgins, Wong, Badger, Ogden, & Dantona, 2000) who developed an effective empirically
based treatment for adult cocaine abuse entitled ‘‘Community Reinforcement Approach’’
(CRA).
CRA has strong empirical support, and it is theoretically compatible with MST. Key
components of CRA are the following:
(a) consistent tracking of substance use through frequent urine screens, with vouchers used as rewards for clean drug screens;
(b) functional analyses of drug use to identify triggers for drug use;
(c) self management plans consisting of cognitive behavioral interventions that focus on addressing the emotional, behavioral, and environmental triggers to drug use for the individual; and
(d) development of drug avoidance skills.
In contrast to MST, which focuses primarily on broader environmental risk and
protective factors, CRA focuses very specifically on substance use.
Pilot testing of an integration of MST and CRA was conducted in a randomized MST trial that evaluated the MST as an alternative to emergency psychiatric hospitalization (Henggeler, Rowland, et al., 1997, 1999; Henggeler et al., 2003) and in a quasi-experimental neighborhood-level intervention project (Randall, Swenson, & Henggeler, 1999)."
!Evidence of some efficacy of CRA in ADULT cocaine users:
From NIDA:
"...Higgins and colleagues, from the University of Vermont, demonstrated the efficacy of this treatment in several randomized clinical trials. In one trial, 38 cocaine-dependent adults were randomized to CRA plus vouchers or drug abuse counseling based on a disease-model approach to cocaine dependence (Higgins et al., 1993). In another trial, 40 cocaine-dependent adults were randomized to receive 24 weeks of CRA plus vouchers or CRA only.
Approximately 75% of those who received CRA plus vouchers were retained for the recommended course of 24 weeks of outpatient treatment compared to less than half of those who received drug abuse counseling or CRA alone. Similarly, greater than 50% of patients who received CRA plus vouchers were documented to have achieved at least two or more months of continuous cocaine abstinence compared to a quarter or fewer of those assigned to CRA alone or drug abuse counseling. When followed-up one-year after treatment entry, all treatment groups improved significantly compared to intake status. However, the groups treated with CRA plus vouchers showed greater improvements in measures related to cocaine use than groups treated with the two comparison treatments (Higgins et al., 1995). Dr. Higgins reports high retention rates and noteworthy rates of continuous abstinence for an outpatient treatment. This approach appears to facilitate patients' engagement in outpatient treatment and systematically aids them in gaining substantial periods of cocaine abstinence. This CRA plus vouchers approach shows great promise for effectively treating cocaine dependence in outpatient settings. "

Material relevant to the design of AMBIT tagged here. See @ambit re. this manualized intervention.

There is an academic reference
[[Link|http://ambit-references.tiddlyspace.com/#[[Reference%20for%20AMBIt%20-%20it%20works!]]]]

Adolescent Treatment Models

A Randomized Controlled Trial of a Smoking Cessation Intervention for Pregnant Adolescents
Susan A. Albrecht 4 Donna Caruthers 4 Thelma Patrick 4 Maureen Reynolds 4 Denise Salamie Linda W. Higgins 4 Betty Braxter 4 Yookyung Kim 4 Sara Mlynarchek
Nursing Research November/December 2006 Vol 55, No 6
Randomised Controlled Trial
three groups for teenage smokers
#Teen Freshstart
#Teen Freshstart + Buddy
#Usual Care (Control)
3 time points:
#baseline
#8 weeks post randomisation
#1 year
142 pregnant adolescents who were aged 14 to 19 years ''RATHER SMALL NUMBERS _ UNDER POWERED.''
intervention:
1. ''__TFS__'' intervention consisted of an 8-week group program designed to promote and maintain smoking abstinence ''based on the Cognitive Behavioral Theory'', with ''modifications'' that incorporated ''developmental components of Jessor’s Problem Behavior Theory (Jessor et al., 1991)''. These developmental modifications, which included the addition of a ''peer buddy'' and a ''peer coleader'', were used to target peer modeling and sanctions on smoking. In addition, information pertinent to pregnancy and smoking was provided as didactic content at the beginning of the 8-week program. Therefore, the intervention sessions used a group setting with individual support, peer modeling, and peer sanctions to promote smoking cessation.
2. The ''__~TFS-B__'' group received the same 8-week programming, but the participants were required to identify and bring a ''nonsmoking female of a similar age as their buddy'' to the sessions. The role of the buddy was to reinforce smoking cessation strategies and to provide social support to the participant throughout the study. The integrity of the group intervention delivery was monitored by means of audiotapes of group sessions.
Approximately 25% of the sessions were reviewed by external reviewers by listening to a tape of the intervention (TFS or TFS-B) sessions selected from TFS facilitator trainers.
''Not known if it was MANUALISED'' - NB
''Measures:''
Self Report and Salivary Cotinine
No between group differences pre-Rx
Signif diff UC and TFS-B at 8 weeks (p<0.01)
No differences at 1 year
Need follow up input.

<<tag Amphetamine>>

Effective Family-Based Interventions for
Adolescents With Substance Use Problems:
A Systematic Review
Ashley M. Austin
Mark J. Macgowan
Eric F. Wagner
Research on Social Work Practice 2005; 15; 67
5Star: very clear and thorough Review - picks out effect sizes, clijical significance and good basic description of therapies.
Effective Family-Based Interventions for Adolescents With Substance Use Problems: A Systematic Review
"Family-based" - covers wide range of treatments and theoretical frameworks (Systems, social-ecology, CBT, developmental, etc) - need for treatments that are specific to adolescent needs - not adult Rx's
The intervention studies included in the
review (according to strict criteria) are as follows:
#Multidimensional Family Therapy ([[MDFT]]; [[Liddle et al 2001]]), Clinically significnat changes between the Rx and 12/12 follow up period noted (not between any other period) but signif changes and large effect sizes at all points for MDFT compared to the other two treatment groups (AGT and MEI) - for posttreatment, effect size = 1.46; for 6-month follow-up, effect size = 1.28; and for 12-month follow-up, effect size = 1.66
#Functional Family Therapy ([[FFT]]; [[Waldron et al 2001]]),FFT better when given as //combined Rx// with CBT. "Finally, calculations of clinical significance reveal no clinically significant changes in marijuana use associated with any of the treatment conditions. However, the effect size for changes in marijuana use at posttreatment was large (effect size = 1.00). By the 3-month follow-up, the effect size for changes in marijuana usewas much smaller (effect size = 0.41)".
#Family Behavior Therapy ([[FBT]]; Azrin et al., 1994), (small sample size (29) and no long term follow up, no clinically signif change)
#Brief Strategic Family Therapy ([[BSFT]]; [[Santisteban et al 2003]]), small effect sizes (0.21 for alc, 0.25 for drugs), limited clinicaly signif change.
#Multisystemic Treatment ([[MST]]; [[Henggeler et al 1999]]). Note - poor effect sizes and no between group differnces (esp bad as 78% of the TAU comaprisaon group got no treatment at all!) BUT very good Rx retention in the MST (98%).
NB problems with some earlier studies of these - not primarily directed at reduction/treatment of SUD - tho this noted as an adjunctive advantage.
Quality features:
#Accessibility (home based/outreach capacity
#Address retention in Rx with specific procedures
#Comprehensive (across multiple domains)
#Empirically validated techniques
#Family therapy component
#Parent and peer support re. no-use of Substances
#Focus on meeting INDIVIDUAL needs of youth
Focus on key curative factors - incl psych/emot problems/family conflict/academic performance/peer relats/neighbourhood community support.
#Address developmental issues relevant to adolescence
#Provide/arrange aftercare services.
Most did quite well by these criteria:
Austin's coments on reveiwed studies:
"Each study was a controlled clinical trial comparing at
least two treatment conditions. None of the studies used
random sampling procedures. Instead, adolescents were
obtained through referrals from the Department of Juvenile
Justice, schools, family, and health and mental health
agencies. In general, the samples were small but varied in
size considerably across studies, ranging from 29 to 152.
When evaluated for adequate power (i.e., at least 25 to 30
participants per treatment condition; Chambless et al.,
1998), four of the five studies—MST (N = 118), MDFT
(N= 152), FFT (N= 120), and BSFT (N= 125)—had adequate
power. In contrast, the study of FBT failed to
achieve adequate power with a sample of only 29 participants
divided among two treatment conditions."
CONCLUSIONS:
Thus, findings from the empirical review indicate that
''two of the five interventions (MDFT and BSFT) are probably
efficacious treatments for adolescent substance use
problems and thus have the best evidence to date''.
However, it should be recognized that only the study of MDFT
included follow-ups (6 and 12 months posttreatment)
necessary to demonstrate the long-term efficacy of the
intervention.
Moreover, MDFT was the only intervention
that demonstrated clinically significant changes in substance
use (at the 12-month follow-up) and large effect
sizes at posttreatment, as well as the two follow-up
assessments.
Although they did not meet full criteria for
probably efficacious treatments, empirical review findings
indicate that ''FFT, MST, and FBT each represent a
promising intervention for treating adolescent substance
use problems''.
''Overall, MDFT emerges as the only family-based intervention with empirical support for changes in substance use behaviors that are both statistically significant and clinically significant immediately following treatment and at 1 year posttreatment.''

See [[Szapocznik et al 2000]]
Brief Strategic Family Therapy is best articulated
around three central constructs:
#system,
#structure/patterns of interactions, and
#strategy
BSFT is composed of three intervention processes:
#joining,
#diagnosis, and
#restructuring.
A variety of empirically supported techniques are employed to facilitate each of the three phases.

Alcohol
Brief intervention for <19yr old college students (freshmen) -
Motivational interviewing style, with additional information and advice sheet.
Personalised feedack in 2nd year - comparing their drinking habits to college norms and personalising data + phone calls and invitations to highest risk group to attned further session (most 2nd interviews were over the phone.)
Brief intervention - 1 interview, and telephone/written follow up (high risk offerd 2nd interveiw, but most got telephone 2nd interview if any) yes.
2041 freshmen returned qyuestionnaires (51% of the year's intake) and 508 identified as high risk.
348 of these randomised into Rx and non-Rx control, as well as a smaller "natural history study" cohort - long (4 yr) follow up
RCT. Included collateral information on drinking habits (though not used in data analysis in paper)
Manualised intervention. Standardised measures.
Effective in reducing risks in high-risk group - "Among high-risk participants, 67% of the prevention group had good outcomes over 4 years (resolved, reliably improved, or no change from a baseline score below the risk cutpoint), compared with 55% of controls."

Multiple substances Brief MI not effective with homeless youth... 5star because a difficult client group and relevant findings
"Brief Motivational - for homeless/high risk adolescents - follow up study to Peterson 2006.
Tried to improve on the intervention design to do better.
Effectively unleashed the MI therapists to allow freer, more flexible application: "
"Counselors were provided
many more opportunities to use motivational interviewing (MI),
develop rapport, and facilitate engagement by:
(a) unblinding the experimental condition during assessment and allowing
counselors to intervene at any point in their contact with youth
in the MI condition;
(b) providing counselors and youth with
greater selection and choice for topics of conversation;
(c) dividing the BMI into four shorter sessions that were spread
over a 4-week period;
(d) providing youth with vouchers for
BMI attendance; and
(e) integrating BMI into other existing
case management services by conducting the project within an
existing agency that provides food, hygiene, social activities,
and case management for homeless youth."
Intervention was extended to 4 short sessions over 1 m period.
See Peterson 2006 - same recruitment methods
254 did brief screening (how many approached for this not recorded)
127 recruited, final n=117 (10 imprisoned before, or > 15 days during experimental period)
randomised without urn -
"No signif effects on abstinence or use of CBS or drugs or alcohol.
Either BMI interventions not effective in this group or their presumed enhancements served to decrease the effectiveness rather than increase it (i.e. payments…)
"More likely, the failure to improve on, or even replicate, findings
from the prior study regarding substance use and the association
between engagement and outcome reflects //differences in
sampling//.
Youth in this study were recruited during one agency’s
drop-in services, whereas youth in the initial study were recruited
from a variety of sources (three agencies and on the street).
At baseline, youth in the current study were far less likely to have
used heroin (24.8% vs. 47.2%) or injected drugs (23% vs. 51%,
respectively) than those in our first study.
The most remarkable pattern in the data are the observed robust changes in substance use
rates over time, in the direction toward less drug use for //all//
participants."

Biederman, J., Wilens, T., Mick, E., Spencer, T., & Faraone, S. V. (1999).
Pharmacotherapy of Attention Deficit Hyperactivity Disorder reduces risk for substance use disorder.
Pediatrics, 102, 1-5.
From 1st Edition:
"Biederman et al. (1999) have reported an important study on the risk of developing substance use disorder in adolescence. They followed up male subjects diagnosed with ADHD who were older than 15 at the time of the study. The study compared the rate of substance use disorder in ADHD subjects who had received medication (mean duration of treatment 1.7–7.1 years) with those who had not. None of those treated with medication were receiving treatment at follow-up. The authors found that the untreated ADHD subjects were at significantly increased risk for substance misuse at follow-up compared to non-ADHD controls. Medicated ADHD subjects had a significantly lower risk of substance misuse than the non-medicated ADHD group. Stimulant medication reduced the risk for substance misuse even in the ADHD subjects with a comorbid conduct disorder. "
BUT - see more recent MTA follow up [[Molina et al 2007]]:
Small numbers: 56 medicated vs. 19 unmedicated adolescents
large inter-group differences pre Rx

Author: S. Bucci, A. Baker, S. A. Halpin, L. Hides, T. J. Lewin, V. J. Carr and M. Startup
Year: 2010
Title: Intervention for cannabis use in young people at ultra high risk for psychosis and in early psychosis
Journal: Mental Health and Substance Use: Dual Diagnosis
Volume: 3
Issue: 1
Pages: 66-73
!Abstract:
!!Background:
The aims of this service evaluation were to determine if an early intervention for cannabis use is feasible and effective in reducing cannabis use and improving functional outcomes among young people at ultra high risk (UHR) for psychosis or with early psychosis.
!!Method:
This was a ''naturalistic evaluation'' that included 58 people attending a clinical service for young people at UHR for psychosis or in the early stages of a psychotic disorder. Young people were offered a tiered intervention consisting of motivational interviewing (MI) and cognitive behaviour therapy (CBT) for cannabis use according to the severity of their use. Non-users were provided with brief advice; infrequent cannabis users were offered a four-session brief intervention and regular users were offered an eight-session intervention. Cannabis use was assessed using the Drug Use Scale of the Opiate Treatment Index (OTI) and functioning was assessed using the Global Assessment of Functioning (GAF) at initial assessment and 12 months follow-up.
!!Results:
Intervention for cannabis use was associated with a significant reduction in the average number of cannabis use occasions per day at follow-up. Only one non-cannabis user had commenced using at follow up after brief advice. Baseline cannabis users had lower GAF scores at 12-months in comparison to non-users.
!!Conclusion:
A tiered intervention for cannabis use appears to be feasible and effective for reducing cannabis use among UHR and early psychosis groups, and it is recommended to be tested in a randomised controlled trial.
!DB
Seems to be no outcome measure on effects on conversion to psychosis...

Quote from from [[Marsch et al 2005]]:
We chose to examine..."buprenorphine
because it has a unique profile of effects that are of clinical
utility and may make it an appealing medication to
provide to opioid-dependent youth.17 As a partial agonist,
buprenorphine has a ceiling effect on its agonist activity,
18,19 which greatly increases its safety profile and
limits its abuse liability as well as the possibility of overdose
relative to full-agonist medications such as methadone
hydrochloride.20 Buprenorphine can also dosedependently
block the subjective and physiological effects
of exogenously administered opioids.19,21,22 Because of buprenorphine’s
slow dissociation from the μ–opioid receptor,
discontinuation of buprenorphine treatment results
in reduced withdrawal symptoms relative to
discontinuation of full agonists.22-24 Numerous controlled
trials have demonstrated that buprenorphine is
safe and efficacious in alleviating opiate withdrawal symptoms,
reducing illicit opiate use, and promoting treatment
retention among opioid-dependent adults in detoxification.
21,25-28 Buprenorphine’s safety and efficacy as
a pain medication have also been established in children
and adolescents as well as adults.29-32"

from [[Killen et al 2004]]
"Bupropion hydrochloride, an aminoketone antidepressant, is
also approved as an adjunct in smoking cessation therapy. Several
placebo-controlled efficacy trials with adult smokers have been
published. In the first trial, 6-month abstinence rates were 16% for
placebo and 27% for bupropion (150 mg and 300 mg; Hurt et al.,
1997). In a second trial, 6-month abstinence rates were 25% for
bupropion and 16% for placebo (Hall et al., 2002)."

Self-efficacy as a predictor of treatment outcome in
adolescent substance use disorders,
Compare Psycho Ed and CBT in RCT with measures of Self Efficacy (valid scale - (Perceived self-efficacy is a cognitive process describing patients’ confidence in their ability to abstain from drug use in high-risk situations (Bandura, 1977) - Such cognitive
expectancies are thought to be proximal mediators of the choice to engage in various
activities and serve a prominent role in the initiation and maintenance of behavioral change )
hypotheses:
(1) the higher the self-efficacy, the more likely will be subsequent abstinence, regardless of treatment condition;
(2) a positive urinalysis finding (or higher ratio) at any one time point will be associated with lower self-efficacy at the subsequent time point;
(3) the higher the self-efficacy at any one time point, the higher the self-efficacy will be at the subsequent time point; and
(4) youth assigned to the CBT condition, which focuses on the enhancement of self-efficacy, will show superior self-efficacy relative to youth assigned to a non-CBT condition such as psychoeducation (PET).
88 adolescents consec refrred to OP clinic with DSM-III-R SUD. 62 boys, 26 girls aged 13 to 18 yrs (79 white)
Randomised to closed groups - CBT or Psycho Ed
Situational Confidence Questionnaire (SCQ; Annis, 1987) - validated for adoelscents
Urinalysis, etc
results:
Hypothesis 1. supported - Self Efficacy predicts SU
Hypothesis 2. NOT proven - (lack of) SU in urinalysis predicted Positive Affect at 3/12, but SU didn't predict negative affect nor Self Efficacy at 9/12
Hypothesis 3. supported for negative affect - the heavier the use (at baseline) under Neg Affect situations... the less confidence to resist subsequently under negative affect situations.
Hypothesis 4 not supported - CBT no better than Psycho Ed at boosting situational self-efficacy.
?CRITICAL PERIOD - those with high self efficacy and motivation (at baseline) sought Rx at the time tthey could best capitalise on help?
"It has been assumed that the mechanism of action responsible for the success of CBT
relapse prevention is the acquisition and application of coping skills. Therefore, a pivotal
objective of approaches based on social learning theory to the treatment of SUD is to focus on
the improvement of these deficits. However, the mechanism underlying the relationship
between self-efficacy and better outcomes is still unclear (Maisto, Connors, & Zywiak, 2000).
Our findings provide only ambivalent support for a social learning theory approach. Perhaps a
combination of other factors such as readiness to change, expectancy, therapeutic alliance, or
engagement in treatment are responsible for change in self-efficacy (Kaminer, 2001;
Morgenstern & Longabaugh, 2000)"

Absence of Iatrogenic or Contagion Effects in Adolescent
Group Therapy: Findings from the Cannabis Youth
Treatment (CYT) Study
Joseph A. Burleson, Yifrah Kaminer, Michael L. Dennis
The American Journal on Addictions, 15: 4–15, 2006
Challenges evidence from [[Dishion et al 1999]] see also [[Dishion and Dodge 2005]]
Funding has sometines been withdrawn as a result... they feel this is unjustified... Group Rx CAN be badly run and damaging, but this is not inevitable.
Quotes research by Ang and Hughes:
"Ang and Hughes’s (''Ang RP, Hughes JN. Differential benefits of skills training with antisocial youth based on group composition: A meta-analytic investigation. Schl Psyc Rev. 2001;31:164–185'') meta-analysis of studies of social
skills training in groups of adolescents concluded that groups that were comprised of youth with both no/low and high levels of conduct disorder symptoms had better outcomes than homogenous groups of youth where all had high conduct disorder symptoms. The authors reasoned that the higher reinforcement value for antisocial behavior was more likely to be generated in homogenous high conduct disorder groups than in the mixed groups. These findings were in the opposite direction of being iatrogenic. The low conduct disorder youth in the mixed groups did not get worse; rather the high conduct disorder individuals in these mixed groups did better than their peers who were treated in group of only high conduct disorder youth. This is actually more consistent with common clinical belief that teens can have a positive influence on each other."
Multivariate analyses on 400 participants of the [[CYT]]
Graded groups on:
#Conduct Disorder Scales (CDS)
#Substance-use Frequency Scales (SFS)
Nomain effects on ....
There were no significant multivariate main nor interaction effects involving Time and either
#Gender,
#Age,
#Race, nor
#Treatment Condition.
!Complicated multivariate analyses then followed:
The four dependent measures:
#Substance Frequency Scale (SFS),
#Emotional Problem Scale (EPS),
#Recovery Environment Risk Index(RERI)
#Illegal Activity Scale (IAS)
were analyzed for univariate significance as a function of the ''Individual'' and three ''Group'' (Minimum, Mean and Maximum) ''CDS measures''.
"In effect, the evidence showed that
(1) youth did not generally show differential improvement on substance use frequency as a function of their CDS;
(2) youth did not generally show differential improvement on SFS as a function of the other highest scoring CDS youth; but,
as per the interaction,
(3) groups with high scoring CDS other youth did not adversely affect the target youth.
In fact, youth of average and higher levels of disruption improved just as much on SFS regardless of the presence of the other most disruptive youth. Less disruptive youth actually showed more improvement on SFS in the presence of the most disruptive youth. It should be noted that this interaction effect accounted for only one percent of the variance in change in the index of substance abuse frequency....a result completely counter to the notion of iatrogenic effects but consistent with the meta analyses reviewed earlier."
Concludes with ''recommendations'' on ways to minmmise possibility of iatrogenic effects (thos having proven they are not the case at least in the manualised structured environment of the CYT groups:
(1) the recruitment of adolescents from diverse referral sources,
(2) maintaining group heterogeneity by including prosocial youth, if for no other reason than to replicate a real-world social environment,
(3) employing competent and well trained therapists,
(4) maintaining an effective supervision apparatus, and
(5) conducting manualized interventions that include clear ‘‘trouble shooting’’ protocols (e.g., how to prevent ‘‘war stories,’’ negative and verbally offensive reference toward group members and leaders, as done in CYT.

Tag to substances

<<tag CBS>>

For conclusions see [[Dennis et al 2004]]

CBS treatment
Trial of M.E.T./CBT +/- Contingency Managt
Vs Drug counselling (DC)
in 18 - 25 yr olds (sl too old.)
8 sessions offered, in the CM arm, participants could earn up to $340 for attneding all 8 sessions, and up to $540 for clean urines (incremental increase in rewards for each desired result.) Reinforcing BOTH session attendance AND abstinence… in the CM arm.
208 18-25yr olds from adult Probation screened.
174 passed criteria. 132 randomized to 4 conditions:
(a) MET/CM
(b) DC/CM
(c) MET/no CM and
(d) DC no CM
Population too old for CAMH (just)
Multiple measures.
3 and 6/12 follow up
"Signif advantage for CM with MET/CBT "
"There were few significant main effects for MET/CBT over DC
for the full sample during the active phase of treatment. However,
there were several significant interaction effects suggesting that
MET/CBT combined with CM was associated with better outcomes
than MET/CBT without CM, DC plus CM, and that those
three treatments were significantly more effective than DC without
CM. Finally, there was evidence of continuing improvement during
the 6-month follow-up for those assigned to the MET/CBT
condition."

from [[Marsch et al 2005]]
Why clonidine in the RCT?...."it is a nonnarcotic medication with limited abuse potential33
and it has been widely studied as a detoxification agent
that decreases sympathetic nervous hyperactivity and suppresses
the acute dysphoric state during the opioid withdrawal
period among adults.25,34-37 Although clonidine has
been used with adolescents in the treatment of psychiatric
disorders,38,39 to our knowledge, no controlled studies
have explored its efficacy in the opiate detoxification
of adolescents who may have a shorter history of opioid
abuse and a lower degree of opioid dependence relative
to opioid-dependent adults. Thus, although prior research
has shown that buprenorphine is generally a more
efficacious detoxification agent compared with clonidine
among opioid-dependent adults,25,40,41 the relative
efficacy of these medications in the detoxification of opioid-
dependent adolescents is unknown, as is their relative
efficacy when combined with intensive behavioral
interventions that may improve outcomes"

Comorbidity is THE CENTRAL NARRATIVE in adolescent SUD, rather than a sideline...
Good Summary Review of Dual diagnosis - Comorbidty is [[Cornelius et al 2005 Comorbidity Chapter]]

Papers involved with comorbidity problems are tagged here.

Conrod, P. J., Stewart, S. H., Comeau, N., & Maclean, A. M. (2006).
Preventative efficacy of cognitive behavioral strategies matched to the
motivational bases of alcohol misuse in at-risk youth. Journal of Clinical
Child and Adolescent Psychology, 35, 550 –563.
Alc [[Conrod et al 2008 (Alc)]] study builds on this.
This one looked at AS, Hopelessness (NT in 2008), SS , but not impulsivity.
Didn't allow matching of personality vulnerability to intervention.
Control didn't include standard (non-personaility based) preventive intervention, or an attention-only control.
Schools based in CANADA.
ditto 2008 study, but not selected to groups on basis of personaility traits.
"Only 30% of students who met study eligibility indicated interest in participating in the intervention and provided parental consent to participate in the next phase of the study" -
4882 screened. Non drinkers excluded.
2775 drinkers, 1717 excluded.
Of the eligiible 1063, only 297 agreed to participate -
randomised to Rx groups....
89% fololowed up at 4/12 post Rx.
RCT.. Only one point of f/up.
High attrition from original no. screened. Only high risk kids invited in and many refused to participate… Intention -to-treat analysis…?
[[Foxcroft et al 2002]] found NNT's of 9-12 for most effective prevention strategies… Conrod's NNT was 5.
(N.B. - similar baselines??? Were the Foxcroft studies actually intervening with actively drinking kids or more "universal prevention"? When is "prevention" actually "treatment"?)

Alcohol Prevention
"The current investigation (following on from a separate earlier one for 15.5 yr olds - [[Conrod et al 2006 (Alc)]], and FOLLOWED by [[Conrod et al 2011]]) aims to explore whether or not intervening upon personality risk earlier in adolescence is effective
(...and this time including interventions directed at IMPULSIVITY as well as SENSATION SEEKING [SS], ANXIETY-SENSITIVITY [AS] and NEGATIVE THINKING [NT]) can delay the early growth of drinking and binge drinking, as previous studies have only demonstrated the efficacy of personality-targeted interventions in reducing substance related behaviours in high-risk populations (Conrod et al., 2006; Conrod et al., 2000; Watt, Stewart, Birch, & Berner, 2006)"
2 x 90min Group sessions.
Components: M.I., PsychoEducation, CBT.
Scenario's of risk in personaility variables,
Goal setting exercises, CBT model - 2nd sessions -> personaility-based exercises
2676 14yr (mean age) students in London Boroughs approached. 2271 screening assessed with SURPS (Sub Use Risk Profile Scale) 1022 invited to join who scored more than one standard deviation (SD) above the school mean on one of the four personality risk subscales of the SURPS: negative thinking (NT), anxiety sensitivity (AS), impulsivity (IMP) and sensation seeking (SS). Higher scores in two //subscales// were invited to join Personaility Group...
368 agreed to participate... 20 lost due to unreliable reporting of data
Randomised (199 interventions, 169 Control)
Assessed at Baseline, 6/12 and 12/12.
Valid instruments.
Manualised treatments. No "attentiveness-only" placebo control (i.e. getting assessments but no intervention, etc)
valid measures, etc
REsults:
"baseline bingedrinking predicted 6 and 12 month bingeing.
Intervention group 41% less likely to binge than controls. (41.1% of intervention group were bingeing, cf 64.6% of controls…)
SS personality signifiacntly predicted bingeing, but while 93%of SS drinkers in control group were bingeing at f/up, only 39% of SS intervention group were.
"Very high effectiveness".
NNT for SS personalities was c 2 - 5 (""Of the few universal alcohol prevention programmes that have been shown to be effective, their NNT values ranged from 9 to 12 ([[Foxcroft et al 2002]])), and effects on SS kids were longer lasting than, say, [[McCambridge and Strang 2004]]"

See also [[Conrod et al 2008 (Alc)]] and [[Conrod et al 2006 (Alc)]]
!Author:
P. J. Conrod, N. Castellanos-Ryan and C. MacKie
!Year:
2011
!Title:
Long-term effects of a personality-targeted intervention to reduce alcohol use in adolescents
!Journal:
Journal of Consulting and Clinical Psychology, Volume: 79, Issue: 3, Pages: 296-306
!Abstract:
!!Objective:
To examine the long-term effects of a personality-targeted intervention on drinking quantity and frequency (QF), problem drinking, and personality-specific motivations for alcohol use in early adolescence.
!!Method:
A randomized control trial was carried out with 364 adolescents (median age 14) recruited from 13 secondary schools with elevated scores in Hopelessness, Anxiety-Sensitivity (AS), Impulsivity, and Sensation-Seeking. Participants were randomly assigned to a control no-intervention condition or a 2-session group coping skills intervention targeting 1 of 4 personality risk factors. The effects of the intervention on quantity/frequency (QF) of alcohol use, frequency of binge drinking, problem drinking, and motives were examined at 6, 12, 18, and 24 months postintervention.
!!Results:
Intent-to-treat repeated measures analyses revealed a significant overall intervention effect in reducing problem drinking symptoms, and a Time x Intervention effect on drinking QF and binge drinking frequency. Relative to the control group, the intervention group showed significantly reduced drinking and binge drinking levels at 6 months postintervention and reduced problem drinking symptoms for the full 24-month follow-up period (Cohen's d = 0.33). A significant Time x Intervention x Personality interaction was demonstrated for coping and enhancement drinking motives. In addition to an overall effect of intervention on coping motives, the AS group who received that intervention reported fewer coping motives compared with the AS control group at 12 and 24 months postintervention.
!!Conclusions:
This study provides further evidence showing that personality-targeted interventions reduce drinking behavior in adolescents in the short term. Novel findings were that the interventions were shown to produced long-term effects on drinking problems and personality-specific effects on drinking motives.
!Highlights and summary notes
Four particular personality risk factors for adolescent substance misuse—
*''Hopelessness (H)'',
*''Anxiety Sensitivity (AS)'',
*''Impulsivity (IMP)''
*''Sensation Seeking (SS)''
—which are also linked to risk for specific patterns of psychopathology (Woicik et al., 2009) have
been shown to differentially predict susceptibility to binge drinking, problem drinking symptoms, illicit substance use, and coping and enhancement motivations for substance misuse.
!!!Hopelessness
H is a personality trait most commonly linked to vulnerability to
depression, but was recently also identified as a robust prospective
risk factor for early onset problems with alcohol and drugs (Bolland
et al., 2007; Conrod, Castellanos-Ryan, & Strang, 2010;
Woicik et al., 2009) and has been shown to be associated with
drinking to cope with negative emotions, particularly depressionspecific
emotions (Woicik et al., 2009)
!!!~Anxiety-Sensitivity
By contrast, AS, a personality risk factor for panic-related anxiety disorders and alcohol
misuse in young adulthood (Schmidt, Buckner, & Keough, 2007;
Schmidt, Zvolensky, & Maner, 2006), has been shown to be
associated with risky drinking motivations, particularly drinking to
cope with negative emotions (Cooper, Agocha, & Sheldon, 2000;
Stewart & Devine, 2000)—a motive for drinking that has been
shown to directly lead to drinking problems, //''without necessarily
increasing risk for other drinking behaviors (e.g., binge drinking;
e.g., Conrod et al., 1998, 2006; Schmidt et al., 2007).''//
This pattern of findings explains why AS might serve as a protective factor for
early onset drinking quantity or binge drinking, but not drinking
problems, with some studies (particularly those involving older
high-risk youth) showing unique relationships between AS and
problem drinking symptoms (e.g., Conrod et al., 1998; Topper,
Castellanos-Ryan, Mackie, & Conrod, 2010; Woicik et al., 2009).
!!!Disinhibition (Impulsivity and ~Sensation-Seeking)
Disinhibited traits have been shown to be associated with risk
for a variety of externalizing problems (Cooper, Wood, Orcutt, &
Albino, 2003), particularly the trait of ''impulsivity'', or the tendency
to react to situations without thinking them through.
Studies have shown longitudinal relationships between impulsive personality
and a general tendency to engage in high-risk/externalizing behaviors,
such as drinking, illicit drug use, risky sexual behaviors, and
other antisocial behaviors (Conrod et al., 2010; Finn, Sharkansky,
Brandt, & Turcotte, 2000; Krueger et al., 2002; Mackie, Castellanos,
& Conrod, 2011).
By contrast, there is recent evidence that another disinhibited trait,
''Sensation-Seeking (SS)'', conceptualized as //the need for arousing
and intense experiences//, is ''more specifically related to the
predisposition to substance abuse, and alcohol binge drinking,
more specifically'' (Castellanos-Ryan & Conrod, 2011; Conrod et
al., 2008; Finn et al., 2000).
Furthermore, these two traits of disinhibition have been shown to discriminate on the basis of
motivation for drinking;
Three studies have shown that ''SS is specifically associated with //drinking for enhancement reasons//'' (Comeau et al., 2001; Cooper et al., 1995; Woicik et al., 2009).
By contrast, two independent adult and adolescent samples have
shown that ''IMP correlates positively with most measureable motivations
for drinking'' (Simons, Gaher, Correlia, Hansen, & Christopher,
2005; Woicik et al., 2009), suggesting //a motivationally
''undefined pattern'' of drinking// that is better accounted for by a
general tendency toward disinhibited behavior and poor response
inhibition (Castellanos-Ryan, Rubia, & Conrod, 2011; Woicik et
al., 2009).

!The author/collator:
Is Dr Dickon Bevington and (aside from quoted material) he retains copyright of the layout and notes contained herein.
!These notes are released under license:
Licensed by Dr Dickon Bevington under a ''Creative Commons License'' (Attribution - ~Non-Commercial - No Derivative Works 2.0 UK: England & Wales) These notes can be freely shared (on the same terms as this), so long as the authorship is properly attributed, derivative works are not released, and they are not used for commercial gain. You can [[Seethefulllicensehere|http://creativecommons.org/licenses/by-nc-nd/2.0/uk/]]
!Health Warning:
These are just working notes/an aide memoir, made in preparation for a chapter on Substance Use disorders in the second edition of //"What Works for Whom; a critical review of treatments for children and adolescents"// by Fonagy, Cottrell, Glaser, Williams and Bevington (due for pub 2009, ~WileyBlackwell), and do ''not'' consititute a finished product. No responsibility is claimed for the accuracy of the contents.

!Author:
J. Cornelius, R. Ferrell, T. Chung, M. Vanyukov, A. Douaihy, O. Bukstein, D. Clark, D. Daley, S. Wood and S. Brown
!Year:
2010
!Title:
Double-blind fluoxetine trial of comorbid MDD-CUD youth and pharmacogenetics data
!Journal:
Alcoholism: Clinical and Experimental Research. Conference: 33rd Annual Scientific Meeting of the Research Society on Alcoholism, RSA San Antonio, TX United States. Conference Start
Volume: 34
Issue: 6
!Abstract:
The authors recently completed a first double-blind, placebo-controlled trial of fluoxetine (20 mg) in 70 adolescents and young adults with comorbid major depressive disorder (MDD) and an cannabis use disorder (CUD). All participants also received cognitive behavior therapy and motivation enhancement therapy during the 12-week trial.
A subgroup of those subjects (N=52) participated in a pharmacogenetics study to assess whether the s allele of the serotonin transporter gene (5-HTTLPR) is associated with poorer response to the serotonin agonist fluoxetine.
Significant within-group decreases (p <.001) were noted in depressive symptoms and in number of DSM cannabis dependence criteria across the entire sample.
However, ''no differences were noted between the fluoxetine group and the placebo group on any outcome variable''.
Also, ''no association was found between the presence of the s allele and any outcomes''.
These finding provide ''no evidence of efficacy for fluoxetine for treating MDD-CUD youth''. However, the within-group improvements in depressive symptoms and cannabis-related symptoms across both treatment groups suggest that ''MET/CBT may have been helpful for treating those symptoms''.
No evidence was found that the s allele of the serotonin transporter polymorphism predicts poor treatment response to SSRI medication among comorbid MDD-CUD youth.

Abstract
Recently, a first placebo-controlled study of an selective serotonin reuptake inhibitor (SSRI) medication was conducted among a sample of adolescents with major depression by Emslie et al. [Arch. Gen. Psychiatry 54 (1997) 1031.]. That study demonstrated efficacy for fluoxetine vs. placebo for treating adolescents with major depression. However, to date, no studies have been conducted to assess the efficacy of fluoxetine or any other SSRI medication in adolescents with major depression in
combination with an alcohol use disorder (AUD). In this study, the authors investigated whether fluoxetine decreases the depressive symptoms and the drinking of adolescents with comorbid major depression and an AUD. The authors conducted a 12-week @@open-label@@ study of fluoxetine (20 mg) @@in 13 adolescents with current comorbid major depression and an AUD@@. A significant within-group decrease (improvement) was found for both depressive symptoms and drinking during the course of
the study. The fluoxetine was well tolerated during the study. These data suggest promise for fluoxetine for decreasing both the depressive symptoms and the drinking of adolescents with comorbid major depression and an AUD.
DB notes:
see [[Cornelius et al 2005]] for 5 year follow up...
PharmaFunded
mean age 18.8, SD = 1.4yrs, range 15 - 19 yrs
Only n=13
12 week study only
11 pts had DEPENDENCE, other 2 had ABUSE (DSM criteria)
All got weekly (4 weeks) then bi-weekly supportive psychotherapy and psychiatric monitoring
Start 10mg Fluoxetine for first 2 weeks, then incr to 20mg daily
Results:
During the 12-week course of the study, the mean HAM-D-24 score dropped by 19 points, from a baseline mean score of 26.5 ± 6.4 to an end of study mean of 6.4 ± 4.8, which was a significant improvement.
Drinking days per week - Pre Rx: Mean = 2.6, SD = 1.0 - Post Rx Mean=1.5 SD=1.0 (t = 1.9, df = 12, P<0.08 - trend not signif)
Drinks per drinking day: Pre Rx: mean=6.7 SD=5.4, post Rx: mean=3.7 SD=4.3 (t = 3.4, df = 12, p<0.005)
!FUNDING
NB drug company funded:
This work was supported in part by grants from the National Institute on Alcohol Abuse and Alcoholism (P50 AA08746 and R01 AA11929), the National Institute on Drug Abuse (P50 DA05605), the Department of Veterans Affairs (MIRECC to VISN 4, Stars
and Stripes Network), the National Institute on Mental Health (MH30915), @@and Eli Lilly and Company.@@

Long term follow up of [[Cornelius et al 2001]]
"Acute phase and five-year follow-up study of fluoxetine in adolescents with major depression and a comorbid substance use disorder: A review"
Jack R. Cornelius T, Duncan B. Clark, Oscar G. Bukstein, Boris Birmaher,
Ihsan M. Salloum, Sandra A. Brown
Addictive Behaviors 30 (2005) 1824–1833
AND (appears to be the same study)...
Cornelius Clark Bukstein Birmaher Kelly Salloum Walters Matta Wood (2005) Fluoxetine in Adoelscents with Comorbid Major Depression and and Alcohol misuse disorder: a five year follow up study. Journal of Dual Diagnosis, 2 (1) 2005.
Very small study but one of the only ines there is and long follow is helpful.
No control, etc...
Abstract
This paper reviews the results of an acute phase trial and a five-year follow-up study of fluoxetine in adolescents with major depression and a substance use disorder (SUD). This study included a 12-week open label acute phase study of 13 comorbid adolescents, followed by comprehensive assessments conducted 1, 3, and 5 years after entry into an acute phase fluoxetine trial. The results of the acute phase study and of the 1, 3, and 5-year follow-up assessments have already been published in four papers. The current paper was designed to cover the results of the study across the entire 5-year time spectrum of the study, and to summarize the clinical results across that entire time period.
The @@data from this pilot study suggest that the long-term (5-year) clinical course for the Alcohol Dependence, Cannabis Dependence, and academic functioning of comorbid adolescents following acute phase treatment with SSRIs is generally good. However, the long-term clinical course for the Major Depression of that comorbid adolescent population is surprisingly poor.@@
@@at 5 year follow up:@@
subjects ranged in age from 20 to 24 years of age, with most being towards the upper part of that age range. The major developmental issue that they were typically dealing with at that age was the completion of college and the entry into the work force.
@@results (at 5 year follow-up):@@
Three of the 10 subjects demonstrated a current diagnosis of MDD, and an additional 3 demonstrated MDD In Partial Remission (IPR).
In contrast, all 10 had demonstrated a current diagnosis of MDD at the baseline of the acute phase study, 6 had demonstrated a current diagnosis of MDD and one MDD IPR at the one-year follow-up evaluation, and 7 had demonstrated a current diagnosis of MDD and 1 MDD IPR at the 3-year follow-up assessment.
The number of DSM IV diagnostic criteria for MDD at the fiveyear follow-up evaluation was significantly lower than that which had been demonstrated at the baseline of the acute phase study (t =7.22, df =9, p <0.001), and was also significantly
lower than the level noted at the three-year follow-up evaluation (t =3.12, df =9, p =0.012)."
[DB - But while the SUD's had tended to reduce/remit, the MDD had tended to relapse throughout the follow up period - suggesting the SUD's didquite well but the individuals remained vulnerable to depressive relapse... "Eight of the subjects (80%) had met diagnostic criteria for current Major Depressive Disorder at least once during the five year follow-up period, which means that they had met criteria for that disorder at least once at either the one-year, the three-year, or the five-year follow-up"..."All of the subjects had chosen to discontinue their antidepressant medication within two months of completing their acute phase trial of fluoxetine. The reason that they generally gave for discontinuing their medication was that they no longer felt very depressed, and therefore did not need it any more. However, @@a majority of the subjects (6 of the 10 subjects) had chosen to restart antidepressant medication between the end of the acute phase study and the 5-year follow-up assessment.@@"
''@@(80%) suffered a recurrent episode of major depression during the five-year follow-up period@@''
''@@the course of the alcohol and cannabis disorders was better than is typically seen with adults, but the course of the major depressive disorders was at least as bad among the comorbid adolescents as is typically seen among comorbid adults@@''
SUD's:
''Alcohol''
10/10 had AUD at baseline (9 dependent, 1 abuse)... at 5 yrs only 1/10 (and 3 pts in partial remission).. the number of DSM IV diagnostic criteria for AUD at the five-year follow-up evaluation was significantly lower than that which had been demonstrated at the baseline of the acute phase study (t =8.13, df =9, p < 0.001), but was not significantly lower than the level noted at the three-year follow-up evaluation.
''CBS''
5/10 had CBS dependence at baseline, ...at 5 yrs 0/10 had dependence (1 had In Partial Remission, 1 CBS abuse) ... number of DSM IV diagnostic criteria for Cannabis Dependence at the fiveyear follow-up evaluation was significantly lower than that which had been demonstrated at the baseline of the acute phase study (t =2.52, df =9, p =0.033)but was not significantly
lower than the level noted at the three-year follow-up evaluation.
!Funding
This research was supported in part by grants from the National Institute on Alcohol Abuse
and Alcoholism (R01 AA013370, R01 AA015173, R01 AA11292, R21 AA014396, K02
AA00291, K08 AA00280, K24 AA00301, and P50 AA08746); the National Institute on
Drug Abuse (R01 DA14635, P50 DA05605, Clinical Trials Network); and a grant from the
Veterans Administration (MIRECC to VISN 4).
NB they acknowledge support from Eli Lilly in [[Cornelius et al 2001]] but not here...??

Check actual reference - chapter 16 from book (have paper copy)
Authors: Cornelius, Clark, Bukstein, Salloum
Good general review of the field of [[Comorbidity]]

J.R. Cornelius, O.G. Bukstein, A.B. Douaihy, D.B. Clark, T.A. Chung, D.C. Daley, D.S. Wood, S.J. Brown. (2010) Double-blind fluoxetine trial in comorbid MDD–CUD youth and young adults. Drug and Alcohol Dependence 112; 39–45.
!Abstract:
!!Objective:
This study compared the acute phase (12-week) efficacy of fluoxetine versus placebo for the
treatment of the depressive symptoms and the cannabis use of adolescents and young adults with comorbid major depression (MDD) and a cannabis use disorder (CUD) (cannabis dependence or cannabis abuse). We hypothesized that fluoxetine would demonstrate efficacy versus placebo for the treatment of the depressive symptoms and the cannabis use of adolescents and young adults with comorbid MDD/CUD.
!!Methods:
We conducted the first double-blind placebo-controlled study of fluoxetine in adolescents and
young adults with comorbid MDD/CUD. All participants in both treatment groups also received manualbased cognitive behavioral therapy (CBT) and motivation enhancement therapy (MET) during the 12-week course of the study.
!!Results:
Fluoxetine was well tolerated in this treatment population. No significant group-by-time interactions
were noted for any depression-related or cannabis-use related outcome variable over the 12-week
study. Subjects in both the fluoxetine group and the placebo group showed significant within-group
improvement in depressive symptoms and in number of DSM diagnostic criteria for a CUD. Large magnitude decreases in depressive symptoms were noted in both treatment groups, and end-of-study levels of depressive symptoms were low in both treatment groups.
!!Conclusions:
Fluoxetine did not demonstrate greater efficacy than placebo for treating either the depressive
symptoms or the cannabis-related symptoms of our study sample of comorbid adolescents and
young adults. The lack of a significant between-group difference in these symptoms may reflect limited medication efficacy, or may result from efficacy of the CBT/MET psychotherapy (see [[Cornelius et al 2011 - CBT/MET]]) or from limited sample size.

Follow on from CYT studies
!Author:
J. R. Cornelius, A. Douaihy, O. G. Bukstein, D. C. Daley, S. D. Wood, T. M. Kelly and I. M. Salloum
Year: 2011
!Title:
Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents
Journal: Addictive Behaviors
Volume: 36
Issue: 8
Pages: 843-848
!Abstract:
!!Objective:
Behavioral therapies developed specifically for co-occurring disorders remain sparse, and such therapies for comorbid adolescents are particularly rare. This was an evaluation of the long-term (2-year) efficacy of an acute phase trial of manualized cognitive behavioral therapy/motivation enhancement therapy (CBT/MET) vs. naturalistic treatment among adolescents who had signed consent for a treatment study involving the SSRI antidepressant medication fluoxetine and CBT/MET therapy for comorbid major depressive disorder (MDD) and an alcohol use disorder (AUD). We hypothesized that improvements in depressive symptoms and alcohol-related symptoms noted among the subjects who had received CBT/MET would exceed that of those in the naturalistic comparison group that had not received CBT/MET therapy.
!!Methods:
We evaluated levels of depressive symptoms and alcohol-related symptoms at a two-year follow-up evaluation among comorbid MDD/AUD adolescents who had received an acute phase trial of manual-based CBT/MET (in addition to the SSRI medication fluoxetine or placebo) compared to those who had received naturalistic care.
!!Results:
In repeated measures ANOVA, a significant time by enrollment status difference was noted for both depressive symptoms and alcohol-related symptoms across the two-year time period of this study, with those receiving CBT/MET demonstrating superior outcomes compared to those who had not received protocol CBT/MET therapy. No significant difference was noted between those receiving fluoxetine vs. those receiving placebo on any outcome at any time point.
!!Conclusions:
These findings suggest long-term efficacy for an acute phase trial of manualized CBT/MET for treating comorbid MDD/AUD adolescents. Large multi-site studies are warranted to further clarify the efficacy of CBT/MET therapy among various adolescent and young adult comorbid populations.

J.R. Cornelius, A. Douaihy, O.G. Bukstein, D.C. Daley, S.D. Wood, T.M. Kelly, I.M. Salloum (2011) Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/MET) in a treatment trial of comorbid MDD/AUD adolescents. Addictive Behaviors 36; 843–848
!Abstract:
!!Objective:
Behavioral therapies developed specifically for co-occurring disorders remain sparse, and such
therapies for comorbid adolescents are particularly rare. Thiswas an evaluation of the long-term(2-year) efficacy of an acute phase trial ofmanualized cognitive behavioral therapy/motivation enhancement therapy (CBT/MET) vs. naturalistic treatment among adolescents who had signed consent for a treatment study involving the SSRI antidepressant medication fluoxetine and CBT/MET therapy for comorbid major depressive disorder (MDD) and
an alcohol use disorder (AUD).Wehypothesized thatimprovements in depressive symptoms and alcohol-related symptoms noted among the subjects who had received CBT/MET would exceed that of those in the naturalistic comparison group that had not received CBT/MET therapy.
!!Methods:
We evaluated levels of depressive symptoms and alcohol-related symptoms at a two-year follow-up evaluation among comorbidMDD/AUD adolescentswho had received an acute phase trial of manual-based CBT/ MET (in addition to the SSRI medication fluoxetine or placebo) compared to thosewho had received naturalistic care.
!!Results:
In repeated measures ANOVA, a significant time by enrollment status difference was noted for both depressive symptoms and alcohol-related symptoms across the two-year time period of this study, with those receiving CBT/MET demonstrating superior outcomes compared to those who had not received protocol CBT/MET therapy.
No significant differencewas noted between those receiving fluoxetine vs. those receiving placebo on any outcome at any time point.
!!Conclusions:
These findings suggest long-term efficacy for an acute phase trial of manualized CBT/MET for treating comorbid MDD/AUD adolescents. Large multi-site studies are warranted to further clarify the efficacy of CBT/MET therapy among various adolescent and young adult comorbid populations.
Data from two-year follow-up assessment in order to provide a first preliminary assessment of the
long-term efficacy of CBT/MET among comorbid MDD/AUD youth

Mainly alcohol
Social ecological - engaging pts in non-SU-related activities
28 days treatment
Age mean 19.6yrs (undergraduates) and //non-clinical//
Sample 30
RCT.
Alternative activities Vs Substance reduction Vs no Rx
Some effectiveness.
Not very strong paper for purpose of review (age) but the group instructed to engage in alternative activities did so, and recorded signif less alcohol, and less SU days - and NB no bias by rewarding decr in SU, as told "You get a reward reagrdless of outcome of SU questionnaire.."

Cottrell D, Boston P (2002)
!Practitioner Review:The effectiveness of systemic family therapy for children and adolescents
Journal of Child Psychology and Psychiatry 43:5 (2002), pp 573–586
!DB summary:
Cottrell and Boston highlight the problems associated with assessing outcomes according to symptoms only, especially as the therapies under examination become increasingly multi-systemic in their orientation. Meaningful outcomes are as likely to be found (even if measuring them is another challenge altogether) in changes outside of the domain of the child’s/adolescent’s symptoms, such as the domains of adaptation, transactional relationships, mechanisms of change, or service satisfaction. A proxy measure for the latter, particularly relevant in the field of adolescent SUD, would be measures of engagement (see section below) and treatment retention. But meaningful ways to capture the outcomes of treatment for a particular index adolescent on, say, parental substance misuse or family boundary-keeping, are elusive to say the least.

: J Psychoactive Drugs. 2004 Mar;36(1):27-33.Links
Assessing the effectiveness of community-based substance abuse treatment for adolescents.
Dasinger LK, Shane PA, Martinovich Z.
see also [[Morral et al 2006 RAND]]
Abstract
The Adolescent Treatment Models initiative, a 10-site, multimodality, prospective study, was designed to evaluate adolescent substance abuse treatment outcomes and to assess the relative efficacy of different treatment models. Based upon longitudinal data gathered at multiple assessment points using a standardized instrument, treatment outcome trajectories were determined for a cohort of 1,057 adolescents from entry into substance abuse treatment until 12 months post-intake. Client outcomes on substance use and program effectiveness were explored across individual treatment programs and levels of care. @@Strong treatment effects, defined as a significant reduction in alcohol and other drug use at three months post-intake, were found.@@
The reductions of greatest magnitude in relation to pretreatment use occurred among adolescents in residential treatment.
@@Within level of care, few significant differences in treatment effects were found between programs.@@
Relapse effects, defined as an increase in substance use at 12 months relative to three months, were observed across nearly all programs, but varied in relation to treatment modality. This is @@most evident among those entering residential treatment, with the highest rate of relapse occurring among adolescents in long-term residential treatment care.@@
@@Despite strong evidence of treatment effectiveness, continuing care is vital to maintenance of treatment benefit.@@
DB text:
the programs in the ATM study were still found to be effective in and of themselves, and this supported findings in an earlier examination of ATM data by Dasinger et al (2004), in which treatment effects (particularly those observed at 3 months post treatment) were considerably more impressive. Long Term Residential treatments in that study showed the greatest effects at 3 months (90 day alcohol and other drug use decreasing from 72.1 days at baseline to 10.8 days at 3 month follow-up, an 85% reduction, whilst Short Term Residential programs achieved a 71% reduction, and Outpatient/Intensive outpatient programs managed 30% reductions), but equally Long Term Residential subjects demonstrated the greatest relapse rates at one year, and despite the significant differences between the treatment models, Dasinger et al were not able to demonstrate different effectiveness between different treatments within any particular level of care (outpatient, short or long term residential.)
A number of possible explanations are offered for the apparently poor showing in the RAND Corporation’s (Morral et al) examination of the ATM data. It is possible that, as a selection of treatments (that were put forward by CSAT as those particularly showing promise) they are all performing well, for which reason between-treatment comparisons do not show significant differences. It is also possible that by examining outcomes at 12 months after treatment entry (rather than ‘in-treatment monitoring’ as one might expect for, say, diabetes or schizophrenia) this underplays and underestimates the chronicity and pervasiveness of adolescent SUD as a condition (Kazdin, 1987; McLellan et al, 2005), so that a single-episode treatment for the chronic portion of the adolescent SUD population makes no more sense than would a time-limited intervention to control a diabetic’s blood sugar. The implications of this echo the conclusions of Dasinger et al; that attention to continuing care is vital to maintain early treatment benefits.

Alcohol & Alcoholism Vol. 39, No. 3, pp. 166–177, 2004
PHARMACOTHERAPEUTIC TRIALS IN ADOLESCENT ALCOHOL USE DISORDERS: OPPORTUNITIES AND CHALLENGES
Good review worth quoting as reference text.
Jusification for using pharmacological interventions in adolescent alcoholics:
"Some adolescents with alcohol dependence will not live to
adulthood if left untreated. Therefore, medications that are
shown to be useful adjuncts to psychosocial treatments for
adolescent alcohol use disorders may help to reduce disease
prevalence, morbidity and mortality."

Reductions in and relations between bcravingQ and drinking
in a prospective, open-label trial of ondansetron in
adolescents with alcohol dependence
Dawes et al
Addictive Behaviors 30 (2005) 1630–1637
ABSTRACT:
"Recently, we reported that ondansetron (a 5-HT3 antagonist) as an adjunct to cognitive behavioral therapy (CBT) produced significant within-group decreases (improvement) in drinking in adolescents with alcohol dependence. We previously have hypothesized that the mechanism of ondansetron treatment response in adolescents with alcohol dependence should be similar to early onset adult alcoholics, wherein blockade of serotonin-3 receptors may decrease dopamine release and subsequent alcohol consumption and craving. We now suggest that one mechanism by which ondansetron diminishes drinking in adolescents with alcohol dependence is through a reduction in @@craving@@ as measured by the @@__Adolescent Obsessive–Compulsive Drinking Scale (A-OCDS)__@@.
We conducted an 8-week, prospective, open-label study of ondansetron (4 Ag/kg b.i.d.) in 12 adolescents (age 14–20 years) who had alcohol dependence. Results showed that "irresistibility" and total scores as measured by the A-OCDS were correlated significantly with drinking indices (drinks / day, percent days abstinent) at the end of treatment, and that @@"irresistibility"@@ and @@total A-OCDS@@ scores decreased significantly by the end of treatment.
These preliminary results suggest that the A-OCDS can be useful as an outcome measure in clinical studies of adolescents with alcohol dependence."
@@DB: Primarily a test drive for the A-OCDS, (piggy-back study on the prelim open label study of Ondansetron [[Dawes et al Ondansetron 2005]] alongside this.)@@
"An adolescent version of the OCDS, the Adolescent Obsessive–Compulsive Drinking Scale (A-OCDS), has been developed recently (Deas, Roberts, Randall, & Anton, 2001) - ... - The A-OCDS yields a total score and two subscales, birresistibilityQ and binterference.Q The A-OCDS has been shown to be specific and sensitive to identify problematic drinking in adolescents and young adults who were college students (Deas, Roberts, Randall, & Anton, 2002) or were admitted to a dual-diagnosis inpatient unit (Deas, Thomas, Randall, & Anton, 2002). In both of these studies, threshold scores were used to indicate the presence of problem drinking, though none of the participants had been diagnosed with an alcohol use disorder.
The utility of the A-OCDS as a quantitative measure of the severity of craving in adolescent alcoholics is the topic of an article in this issue of Addictive Behaviors (Thomas & Deas, 2005). The A-OCDS has yet to be used to examine changes in drinking and craving in adolescents over the course of treatment for alcohol use disorders, @@which is the focus of the present study.@@"
[[Ondansetron]] known to be effective in early onset alcoholism in adults
Particiapants:
Enrolled participants were seeking treatment for DSM-IValcohol dependence (7 males and
5 females) and were between the ages of 14 and 20 years.

Addictive Behaviors 30 (2005) 1077–1085
''A prospective, open-label trial of ondansetron in adolescents with alcohol dependence''
Michael A. Dawesa,*,1, Bankole A. Johnsona, Nassima Ait-Daouda,
Jennie Z. Maa, Jack R. Corneliusb
@@gets 4star because nothing else around and a promising start - need controlled stufdy with more numbers/power now..@@
Abstract
[[Ondansetron]] has been shown to be effective in the treatment of early-onset adult alcohol dependence. To date, no studies have been conducted in adolescents with alcohol dependence to assess the feasibility, safety, tolerability, and potential utility of ondansetron treatment. We conducted an 8-week, prospective, open-label study of ondansetron (4 Microgrammes/kg b.i.d.) in 12 adolescents who had alcohol dependence. Oral ondansetron was safe and well tolerated in our sample. Adverse events were mild and resolved quickly without intervention. No subjects discontinued due to adverse events. Intent-totreat
analyses showed a significant within-group decrease (improvement) for drinks/drinking day (t= - 3.10, df=11, p=0.01), as well as decreases in drinks/day (t= - 2.01, df=11, p=0.06) and percentage of days abstinent (t=1.45, df=11, p=0.18). These preliminary data suggest that ondansetron is safe and well tolerated in adolescents with alcohol dependence. Findings of decreased drinking underscore the need for future double-blind, placebo-controlled studies in this adolescent population.
@@Rationale for Ondansetron:@@
"Ondansetron has been shown to be efficacious only in the treatment of EOA adults who had developed alcohol dependence more than 15 years prior to study enrollment (Johnson et al., 2000; Kranzler, Pierucci-Lagha, Feinn, & Hernandez-Avila, 2003). Johnson et al ''[Johnson, B. A., Roache, J. D., Javors, M. A., DiClemente, C. C., Cloninger, C. R., Prihoda, T. J., et al. (2000). "Ondansetron for reduction of drinking among biologically predisposed alcoholic patients: A randomized controlled trial. JAMA: The Journal of the American Medical Association, 284, 963–971]'' showed that in a sample of EOA adults (N=161), but not in late-onset alcohol-dependent (LOA) adults (N=160), ondansetron was superior to placebo at improving drinking outcomes. Although the 1-, 4-, and 16-Ag/kg doses of ondansetron twice per day all decreased alcohol consumption significantly in EOA adults, the 4-Ag/kg dose appeared to result in the best drinking outcomes.
In a recent prospective, open-label study of ondansetron for EOA adults compared with LOA adults (N=40; 20 EOA, 20 LOA), EOA adults had significantly greater decreases in drinks/day, drinks/drinking day, and alcohol-related problems (Kranzler et al., 2003) ''[Kranzler, H. R., Pierucci-Lagha, A., Feinn, R., & Hernandez-Avila, C. (2003). Effects of ondansetron in early versus late-onset alcoholics: A prospective, open-label study. Alcoholism, Clinical and Experimental Research, 27, 1150–1155.]''. In both of these EOA adult samples, ondansetron was safe and well tolerated."
SAMPLE:
We enrolled 12 treatment-seeking subjects (7 males and 5 females) between the ages of
14 and 20 years. All subjects had a DSM-IV diagnosis of alcohol dependence. Subjects
were currently drinking greater than 12 alcohol-containing drinks in the last 30 days prior to
enrollment and reported impairment due to drinking.
Quite a few exclusions:
if they had
#substance abuse or dependence other than for alcohol, marijuana, or nicotine within 4 weeks prior to screening or
#other psychiatric comorbidity of sufficient severity to preclude participation in the trial.
#subjects treated with medication for attention deficit hyperactivity disorder.
#clinically significant elevation of liver enzymes or serious medical co-morbidity that required medical intervention, including severe withdrawal symptoms;
#female subjects who were pregnant, lactating or breastfeeding,
#or not adhering to an acceptable form of contraception at any time during the study;
#subjects with histories of severe or life-threatening adverse reactions to medications;
#subjects who had undergone inpatient or outpatient treatment for alcohol abuse or dependence within the last 30 days;
#subjects forced to participate in an alcohol treatment program to maintain their liberty;
#members of the same household; and
#subjects taking concurrent medications having a potential effect on alcohol consumption and related behaviors, or mood.
But...@@still quite a realistic sample@@ (DB)....."The mean age was 18.0 years (range: 14–20 years) ...the ''majority of adolescents had disruptive behavior disorders'' and ''three had mood disorders''. In addition to alcohol dependence, ''10 of 12 subjects also met DSM-IV-R criteria for cannabis dependence.''"
ASsesst:
__pre Rx__
Children’s Interview for Psychiatric Syndromes (ChIPS)
Adoelscent Diagnositic Interview
TLFB (and weekly thereafter)...
__Rx:__
4 Microgramme/kg p.o. b.i.d. of ondansetron, administered in opaque gelatin capsules. All subjects received weekly cognitive behavioral therapy (CBT), with motivational enhancement, after an initial functional analysis.
NO CONTROL
OUTCOME MEASURES:
#SE's
#Pill counts were conducted weekly to assess compliance.
#Primary drinking outcome was self-reported alcohol consumption
##frequency: drinks/day,
##severity: drinks/drinking day
##abstinence: percentage of days abstinent
OUTCOMES:
Intent-to-treat analyses showed significant within-group decreases (improvement) for drinks/drinking day (t= - 3.10, df=11, p=0.01). During the course of the study, drinks/day (t= - 2.01, df=11, p=0.06) and percentage of days abstinent (t=1.45, df=11, p=0.18) also decreased.

HUMAN PSYCHOPHARMACOLOGY
A Double!Blind, Placebo Controlled Trial of Sertraline in Depressed Adolescent Alcoholics - A Pilot Study
DEBORAH DEAS CARRIE RANDALL JAMES St ROBERTS and RAYMOND ANTON
In order to preliminarily evaluate the efficacy safety and tolerability of the serotonin reuptake inhibitor sertraline in the treatment of adolescents with a primary depressive disorder and a comorbid alcohol use disorder. A 12 week double blind placebo-controlled trial of sertraline plus cognitive behavior group therapy was conducted
''Subjects''
were @@10 outpatient treatment-seeking adolescents@@ - - - @@NB very low power@@
''Baseline assessment''
included the K-SADS/HAM-D/SCID and the Time-Line Follow-Back.
The HAM-D and the Time-Line Follow-Back were performed weekly thereafter
Both groups showed a signifcant reduction in depression scores with an average reduction between baseline and endpoint
HAM-D score of -9.8 (F(1,8) = 26.14, p<0.001) though @@there were no signifcant group differences.@@
There was an overall reduction in Percent Days Drinking "PDD" (F(1,8) = 8.90, p<0.02) and in Drinks Per Drinking Day (F(1,8) = 20.48, p<0.002) however, @@there were no group differences@@
Depression responders tended to have higher baseline PDD than non-responders (not quite signif) and change in HAM-D scores tended to correlate with change in PDD (r = 0.57, p=0.09). Our data support that sertraline is safe and well tolerated in the treatment of adolescents with depression and alcohol dependence. Small sample size and cognitive behavior group therapy
given to all subjects may limit the lack of group differences.
!FUNDING
This research was supported by grant AA09650 from the National Institute of Alcohol and Alcoholism NIAAA

Naltrexone Treatment of Adolescent Alcoholics: An Open-Label Pilot Study
Deborah Deas, M.D.,1 M.P.H., Kim May, Ph.D.,2 Carrie Randall, Ph.D.,1
Natalie Johnson, M.A.,1 and Raymond Anton, M.D.
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume 15, Number 5, 2005 Pp. 723–728
ABSTRACT
''Objective:''
This 6-week open-label trial of naltrexone was conducted in a preliminary fashion to determine whether naltrexone would be safe, well tolerated, and lead to a reduction in alcohol consumption in adolescents with alcohol dependence.
''Method:''
Five (@@NB VERY SMALL NUMBERS@@) outpatient treatment-seeking adolescents who met Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for alcohol dependence were recruited.
The Child Schedule for Schizophrenia and Affective Disorders (K-SADS), Structured Clinical Interview for DSM (SCID), and the Family History Questionnaire were administered at baseline.
The Time-Line Follow-Back (TLFB) and two craving scales (Adolescent Obsessive Compulsive Drinking Scale [A-OCDS] and a craving analog scale) were administered at baseline and weekly thereafter.
@@Each subject received a 10-day supply of Naltrexone (50 mg) and a 100-mg riboflavin capsule.@@
Subjects were instructed to take naltrexone and riboflavin simultaneously.
''Results:''
Overall, the average drinks per drinking day (DDD) decreased significantly from baseline to the end of week 6 with an average reduction of 7.61 standard drinks.
There was a significant reduction in the average A-OCDS total score, A-OCDS Irresistibility subscale score, and craving analog score.
Nausea was the only side-effect reported, and there were no elevations of liver enzymes. Naltrexone was well tolerated by the alcohol-dependent adolescent.
''Conclusions'':
Our data suggest that naltrexone is safe and well tolerated in adolescent alcoholics. Naltrexone may lead to a significant reduction in alcohol consumption and craving in adolescent alcoholics, but larger, randomized, controlled trials are needed.

[[Copyright - licensed material]]

CBS
''The Cannabis Youth Treatment (CYT) experiment: rationale, study design and analysis plans''
Dennis et al 2002 Addiction, 97 (Suppl 1), 16–34
median duration of outpatient treatment in practice is only about 2 months,
See [[Diamond et al 2002]] for the interventions...
@@NB reviewed in [[Waldron and Kaminer 2004]]@@
provides a description of the rationale, study design, treatments
and assessment procedures used in the Cannabis Youth Treatment (CYT)
experiment.
"designed to
(a) test the relative effectiveness, cost and benefit– cost of five promising treatment interventions under field conditions and
(b) provide evidence based manual-guided models of these interventions to the treatment field."
''Re. robustness of trials''
"CYT is the largest randomized field experiment ever undertaken" to evaluate the relative effectiveness of adolescent outpatient drug abuse treatments. It incorporated many features that have been recommended to establish efficacious behavioral interventions including:
(a) replicating interventions by independent research teams in different settings (including actual practice sites);
(b) comparing interventions with other well implemented interventions;
(c) evaluating interventions with a clearly defined target population that mirrors the population found in regular practice settings;
(d) assessment of subsequent treatment and symptom status during follow-up; and
(e) the use of treatment manuals and therapist training and monitoring procedures (Chambless & Hollon 1998).
!"The five treatment models were evaluated in two research arms or studies..."
A. In the ‘incremental arm’, each subsequent intervention builds upon earlier ones both clinically and in terms of resources: (MET/CBT5)<(MET/CBT12)<FSN.
B. In the ‘alternative arm’, additional services are provided but in a way that requires fewer total resources (e.g. providing substance use treatment via family therapy instead of family therapy in addition to substance abuse treatment): MET/CBT5, or ACRA, or MDFT.
"The primary goal was to produce manual guided treatment models that could be rigorously evaluated and readily disseminated to the field."
''Re. Non-ethical nature of having a non-treatment control for Cannabis intervention study (CYT)''
“CSAT explicitly ruled out an untreated control group as unethical because past studies have shown consistently that untreated or minimally treated adolescents become worse or fail to improve
( Jessor & Jessor 1975; Beschner & Friedman 1979; Lewis et al. 1990; Henggeler et al.1991; Azrin et al. 1994; Borduin 1999; Henggeler et al 1999; Hofler et al. 1999; Perkonigg et al 1999; Winters et al. 2000)”
[[MET/CBT]]
[[FSN]]
[[ACRA]]
[[MDFT]]
median duration of outpatient treatment in practice is only about 2 months,
!Patients:
12 - 18 yrs, CBS use in last 90 days,
Included CBS abuse (not just dependency) - more realistic sample... various exclusions, e.g. not other drugs for >13/90 previous days (or days prior to incarceration)
"Of the 1244 adolescents screened, 44% were ineligible
B with over 20% being too severe for outpatient treatment.
This is approximately the same proportion as the
national rates for residential treatment (Dennis
et al 2002a). Of the 702 who were eligible, 600 (85%) agreed
to participate, even though over half the participants
reported they did not think they needed treatment or that
they did not want treatment at this time. Thus, while participation
was ‘voluntary’, it is clear that most adolescents
were under some pressure to participate from their
parents or the criminal justice system (see Webb
et al 2002 for a further discussion of this issue)"
CBS see above yes 80 yes +++ 85 yes 80 245
[[Tetzlaff 2005]] and [[Schell 2005]] for related studies

Michael Dennis, Susan H. Godley, Guy Diamond, Frank M. Tims, Thomas Babor, Jean Donaldson, Howard Liddle, Janet C. Titus, Yifrah Kaminer, Charles Webb, Nancy Hamilton, Rod Funk (2004)
!The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials
Journal of Substance Abuse Treatment 27 (2004) 197–213
CBS
''The Cannabis Youth Treatment Study: The treatment models and preliminary findings.''
See [[Diamond et al 2002]] [[Dennis et al 2002]]
The days of abstinence
per quarter (the solid line on top) increased from 52
(of 90) in the quarter before intake to an average of 65 days
per quarter (+24%) across the four followup periods. The
overall change occurred during active treatment (from
intake to month 3) and was stable across followup, though
individuals did vary (intraclass correlation coefficient
[ICC] = .47). The percent of adolescents in recovery at
each interview increased from 3% at intake to an average of
24% across the four followup periods. Again, across
conditions and sites, change occurred during active treatment,
was stable across followup waves, and individual
adolescents continued to move in and out of recovery
(ICC = .33)
CONCLUSIONS OF CYT
This study examined the relative clinical effectiveness
and cost-effectiveness of five short-term (90 days or less)
outpatient treatments for adolescents with cannabis use
disorders in two randomized trials with 600 adolescents
from four sites. All five CYT interventions demonstrated
significant pre-post treatment effects that were stable in
terms of increasing days of abstinence during the 12 months
after they were randomized to a treatment intervention and
the percent of adolescents in recovery at the end of the
study. Overall, the clinical outcomes were very similar
across sites and conditions. The effect sizes were generally
small (CohenTs f = .1) and varied by measure and site.
See also [[Tetzlaff 2005]] and [[Schell 2005]] for related studies
CYT conclusions
(a) the five treatments can be delivered
in the manner intended and can be differentiated quantitatively
and qualitatively;
(b) the costs of these treatments
differ in predictable ways associated with their intensity but
all are roughly within the bounds now commonly spent on
adolescent outpatient treatment (see French et al., 2002);
(c) the treatments are reasonably acceptable to the adolescents
and their families as evidenced by participation and
retention rates reported above;
(d) many (though certainly not all) of these adolescent cannabis users show significant
improvement in substance use and in other measures
bduringQ treatment (months 0–3) and these improvements
are sustained for significant periods following treatment
completion;
(e) the amount and duration of the clinical
improvements were very similar between sites and across
treatments; and
(f) the cost-effectiveness differences are
moderate to large.
''__Conclusions of CYT:__
"Thus, while the CYT interventions
were relatively effective as initial interventions, they were
not enough to interrupt all future substance use and
problems for many adolescents. For significant subgroups
of clinically referred teens, the conceptualization of their
drug problems as a chronic condition (Kazdin, 1987)
suggests the need to focus more on monitoring and reintervention
or continuing care."''

The relative efficacy of pamphlets, CD-ROM, and the Internet for
disseminating adolescent drug abuse prevention programs:
an exploratory study
Jennifer Di Noia, Ph.D.,a,b,* Traci M. Schwinn, M.S.,a,b Zubin A. Dastur, M.P.H.,c and
Steven P. Schinke, Ph.D.a,
Preventive Medicine 37 (2003) 646–653
@@using CD rOMs and Internet to distribute prevention materials to professionals who will use these is just (or more) effective as using pamplhlets@@
Abstract
''Background.''
Despite the availability of an increasing array of empirically validated adolescent drug abuse prevention programs, program materials and evaluation findings are poorly disseminated. CD-ROM and the Internet hold promise for disseminating this information to schools and agencies that directly serve youth, and to policy-making bodies that exercise control over funds to support adolescent drug abuse prevention programming. However, data on the relative efficacy of these newer technologies over conventional print means of dissemination are lacking.
''Methods.''
Recruited through schools, community agencies, and policy-making bodies, @@188 professionals@@ were randomized to receive prevention program materials
#via pamphlets (55 participants),
#CD-ROM (64 participants), and
#the Internet (69 participants).
Participants completed pretest, posttest, and 6-month follow-up measures that assessed their access to prevention program materials; self-efficacy for identifying, obtaining, and recommending these programs; and their likelihood of requesting, implementing, and recommending prevention programs to their constituents.
''Results''. P
articipants exposed to dissemination via CD-ROM and the Internet evidenced the greatest short- and long-term gains on
accessibility, self-efficacy, and behavioral intention variables.
Conclusions. CD-ROM and the Internet are viable means for disseminating adolescent drug abuse prevention programs to schools,
community agencies, and policy-making bodies, and should be increasingly used for dissemination purposes.

GUY DIAMOND G, JOSEPHSON A (2005)
!Family-Based Treatment Research: A 10-Year Update
J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(9):872–887.
Good General Review of Family therapy - only small section on SUD
MDFT the most developed for SUD in adolescents [[Liddle et al 2001]] and Liddle 2002 (treatment manual for CYT)

CYT CBS
Add-on study from the CYT. Looked at ALLIANCE and outcomes,
meausured via the Working Alliance Inventory (WAI) - a validated instrument.
diff doses - looking at effects of Therapeutic alliance on Rx ATTENDANCE and Rx outcome.
greater than 600 pts
Predicted that better alliance -> better attendance and better outcome, and that patient-rated alliance would better predict than therapist-rated alliance
"EArly alliance //not// very strong assoc with outcomes (Patient-rated alliance accounted for less than 3% of the variance for predicting outcomes at multiple time points)
Alliance (//patient-rated//) DID predict CBS use at 3/12 and 6/12 but not at other times
''NB [[Shirk and Carver 2003]] found that //therapist-rated// alliance was the one that was predictive, not patient-rated...''
Most relaible predictor was baseline SU rates.
See my notes in ""Quotes for planning""...
Note level of COERCION involved in Treatments - CYT no exception:
"In contrast to voluntary participation in
many of the adult studies, adolescents in CYT were
often coerced into treatment by outside agencies and/or
brought to treatment by their parents.
In fact, 61% were referred by juvenile justice, schools, or other social systems,
and 22% were referred by parents.
These conditions may inflate alliance ratings when patients feel they need
to appear compliant with treatment.
Furthermore, most adolescents in the CYT study were not interested in
reducing their marijuana use. Within this sample, 81%
reported that, in general, their substance use was not a
problem, and 74% denied needing services."

Dishion TJ, Dodge KA.
Peer contagion in interventions for children and adolescents: moving toward an understanding of the ecology and dynamics of change.
J Ab Child Psych. 2005;33:395–400
modify their postion from [[Dishion et al 1999]] slightly:
''"The deviancy training dynamic is a process, and may or may not occur depending on the characteristics of the participants,
the skill of the group leader, and the context of the intervention."''

Dishion TJ, McCord J, Poulin F.
When interventions harm: Peer groups and problem behavior.
Am Psych. 1999;54:755–764.
''"Association with deviant peers in early adolescence, under some circumstances, inadvertently reinforces problem behavior."''
Their research was based on pre - early adolescents, though - not generalisable to ALL settings ages...
but gets 5Star as +++ influential
challenged in [[Burleson et al 2006]] - CYT evidence and [[Waldron and Kaminer 2004]]
Modified in [[Dishion and Dodge 2005]]

Drug-screening - Not necessarily effective , ''some evidence it exacerbates risk factors''…
Goldberg, L., Elliot, D. L., MacKinnon, D. P., Moe, E. L., Kuehl, K. S., Yoon, M. et al. (2008). Erratum: "Outcomes of a prospective trial of student-athlete drug testing: The student athlete testing using random notification (SATURN) study".
''__Abstract__'':
"Outcomes of a prospective trial of student-athlete drug testing: The Student Athlete Testing Using Random Notification (SATURN) study" by Linn Goldberg, Diane L. Elliot, David P. MacKinnon, Esther L. Moe, Kerry S. Kuehl, Myeongsun Yoon, Aaron Taylor and Jason Williams (Journal of Adolescent Health, 2007[Nov], Vol 41[5], 421-429).
''Purpose'': To assess the effects of random drug and alcohol testing (DAT) among high school athletes.
''Methods'': This was a 2-year prospective randomized controlled study of a single cohort among five intervention high schools with a DAT policy and six schools with a deferred policy, serially assessed by voluntary, confidential questionnaires. DAT school athletes were at risk for random testing during the full academic year. Positive test results were reported to parents or guardians, with mandatory counseling. Indices of illicit drug use, with and without alcohol use, were assessed at the beginning and end of each school year for the past month and prior year. Potential mediating variables were evaluated.
''Results'': Student-athletes from intervention and control schools did not differ in past 1-month use of illicit drug or a combination of drug and alcohol use at any of the four follow-up periods. At the end of the initial school year and after 2 full school years, student-athletes at DAT schools reported less drug use during the past year (p < .01) compared to athletes at the deferred policy schools. Combining past year drug and alcohol use together, student-athletes at DAT schools reported less use at the second and third follow-up assessments (p < .05).
''Paradoxically, DAT athletes across all assessments reported less athletic competence (p < .001), less belief authorities were opposed to drug use (p < .01), and indicated greater risk-taking (p < .05). At the final assessment, DAT athletes believed less in testing benefits (p < .05) and less that testing was a reason not to use drugs (p < .01)''.
''Conclusions'': No DAT deterrent effects were evident for past month use during any of four follow-up periods. Prior-year drug use was reduced in two of four follow-up self-reports, and a combination of drug and alcohol use was reduced at two assessments as well. ''Overall, drug testing was accompanied by an increase in some risk factors for future substance use.'' More research is needed before DAT is considered an effective deterrent for school-based athletes.
''__Similar findings – reduces drug use but exacerbates risk factors and negative attitudes towards school…__''
Goldberg, L. (2003). Drug testing athletes to prevent substance abuse: background and pilot study results of the SATURN (Student Athlete Testing Using Random Notification) study.
''PURPOSE'': To assess the deterrent effect of mandatory, random drug testing among high school (HS) athletes in a controlled setting.
''METHODS'': Two high schools, one with mandatory drug testing (DT) consent before sports participation, and a control school (C), without DT, were assessed during the 1999-2000 school year. Athletes (A) and nonathletes (NA) in each school completed confidential (A) or anonymous (NA) questionnaires developed for this study, respectively, at the beginning and end of the school year. Positive alcohol or drug tests required parent notification and mandatory counseling without team or school suspension. Thirty percent of the DT athletes were tested. Data were analyzed using the end of the school year measure, adjusted for the initial questionnaire results. Demographics of the athlete sample revealed that mean age was 15.5 years with 81.5% white, 9.6% Hispanic, 4.5% Asian, 2.6% American Indian/Native Alaskan, 1.3% African-American, and 1.3% Native Hawaiian/Pacific Islander.
''RESULTS'': A (n = 276) and NA (n = 507) were assessed at the beginning (baseline) and at the end of the school year (A, n = 159; NA, n = 338). The past 30-day index of illicit drugs (4-fold difference) and athletic enhancing substances (3-fold difference) were lower (p < .05) among DT athletes at follow-up without difference in alcohol use. However, most drug use risk factors, including norms of use, belief in lower risk of drugs, and poorer attitudes toward the school, increased among DT athletes (p < .05). Although a reduction in the illicit drug use index was present among nonathletes at the DT school, at the end of the school year, it did not achieve statistical significance (p < .10).
''CONCLUSIONS'': Random DT may have reduced substance use among athletes. However, ''worsening of risk factors and small sample size suggests caution to this drug prevention approach''. A larger long-term study to confirm these findings is necessary. Copyright Society for Adolescent Medicine, 2003

''Treatment process in the therapeutic community: Associations with retention and outcomes among adolescent residential clients''
Maria Orlando Edelen, (Ph.D.)a,4, Joan S. Tucker, (Ph.D.)a,
Suzanne L. Wenzel, (Ph.D.)a, Susan M. Paddock, (Ph.D.)a,
Patricia A. Ebener, (B.A.)a, Jim Dahl, (Ph.D.)b, Wallace Mandell,
''Journal of Substance Abuse Treatment 32 (2007) 415– 421''
Part of the larger RAND STUDY [[Morral et al 2006 RAND]]
Measuring the therapeutic treatment environment and patient-specific changes in ''Therapeutic Community'' treatment of SUD adoelscents, suing a new instrument the ''DCI - Dimensions of Change Instrument'' (Orlando, M., Wenzel, S. L., Ebener, P., Edwards, M. C., Mandell, W., & Becker, K. (2006). The dimensions of change in therapeutic community treatment instrument. Psychological Assessment, 18, 118–122)
Dichotomize length of stay into <90 days and >90 days (>90 demonstrated to be associated with improved outcomes).
Is there any aspect of TC Rx that the DCI can reliably measure which predicts RETENTION and/or OUTCOME?
Post treatment Outcome measures:
#self-reported abstinence from drug and alcohol use,
#12-step meeting attendance,
#Having a 12-step sponsor,
#engaging in work or school,
#no involvement in illegal activity,
#no exposure to substance-using peers,
...assessed using a past 30-day time frame approximately 3 months after treatment exit.
''AIMS:''
#to identify characteristics that predict treatment retention and posttreatment outcomes and adjust for these characteristics in subsequent analyses.
#to provide evidence for the predictive utility of changes in DCI scores in terms of whether adolescent clients remain in treatment for 90 days or longer.
#to examine whether changes in these components of the TC treatment process, as well as 90-day treatment retention, predict positive outcomes approximately 3 months after leaving treatment.
''Sample''
8 in-pt units in New York, New England, California, and Texas
Data from:
#admission details
#interview in first 2 weeks of admission
#interview after 30 dyas admission
#dishcarge details
#telephone interview c. 30 days post discharge
n = 397 (those who remained in-pts long enough to complete the 30 day assesst; relative to the shorter stayers, this group were more likely to be referred by Crim justice and to name CBS and Alc as drugs of choice.)
Of these 397, only 241 had left Rx at the 6/12 follow up date - the rest were still in the TC or had moved to other residential setting, or were lost to f/up. ''Differences exisited between the sample and those ineligible or lost to F/up...'' - sample more ikely to be White, less likely to be African American, less likely to have been referred by crim justice system, less likely to have been arrrested, etc...
''DCI''
eight distinct factors:
#Community Responsibility (4 items, a = .60 and .75 for baseline and 30-day, respectively);
#Clarity and Safety (6 items, a =.81 and .84);
#Group Process (6 items, a = .78 and .83);
#Resident Sharing, Support, and Enthusiasm (8 items, a = .82 and .86);
#Introspection and Self-Management (7 items, a = .80 and .83);
#Positive Self-Attitude and Commitment to Abstinence (9 items, a = .85 and .86);
#Problem Recognition (5 items, a = .81 and .86); and
#Social Network (3 items, a = .71 and .71)
''Results:''
Very few statisitcally significnat PRE-treatment predictors of postive outcome... (White Vs hispanic, non crim jiustice Vs crim justice route into Rx, etc)
__Re. the DCI, the only three factors significnatly ''associated with increased retention'' (>90 days) were:__
#Positive Self- Attitude and Commitment to Abstinence OR = 1.56 (95% C.I. = 1.03–2.35)
#Problem Recognition OR=1.38 (95% C.I. = 1.01–1.89)
#Social Network OR = 1.38 (C.I.= 1.02–1.87)
''NB these are all individual change items - none of the group/milieu setting items associated with postivie outcomes.''
"Together, these results suggest that it may be beneficial for programs to facilitate development of self-worth and responsibility for one’s actions @@and to encourage adolescents to recognize that they are not without social support outside of the treatment program...@@"
..."The lack of association between the TC environment factors (e.g., community responsibility, clarity and safety, group process, resident support and enthusiasm) and treatment retention was unexpected. One possible interpretation of this finding is that early buy-in to the structured TC environment—that is, believing that it is important for everyone to do their share of work, understanding the requirements for program completion, feeling that the program is a safe place, being actively engaged in program meetings and encounter groups—is insufficient to retain adolescent clients in treatment."
Changes in DCI not associated with post-treatment outcomes, but longer treatment stays correlated with incr attnedance at 12 step mtgs (odds ratio = 2.55; 95% confidence interval = 1.10–5.87; p < 0.05).

!Citation
Edwards, A. C., Gillespie, N. A., Aggen, S. H. and Kendler, K. S. (2013), Assessment of a Modified DSM-5 Diagnosis of Alcohol Use Disorder in a Genetically Informative Population. Alcoholism: Clinical and Experimental Research, 37: 443–451
!Abstract
!!Background
Proposed changes to the upcoming DSM-5 include the following: (i) combining criteria for DSM-IV alcohol abuse (AA) and alcohol dependence (AD) into 1 diagnostic category (alcohol use disorder [AUD]); (ii) exclusion of the “legal problems” (LP) criterion; and (iii) addition of a “craving” criterion. Few published studies empirically assess the potential consequences of the proposed changes.
!!Methods
Using a population-based sample of twins assessed for lifetime AA/AD diagnoses, we explored phenotypic differences across DSM-IV and a modified DSM-5 diagnoses without craving because of its unavailability in the data set. We used factor analysis and item response theory (IRT) to evaluate the potential consequences of excluding the LP criterion from AUD and used twin modeling to examine genetic differences between DSM-IV and the modified DSM-5 diagnoses.
!!Results
The prevalence of AUD was slightly higher than that of DSM-IV diagnoses. Individuals meeting DSM-IV or DSM-5 criteria, but not both, exhibit fewer comorbid diagnoses than those meeting both sets of criteria. Individuals meeting only DSM-5 criteria were slightly less severely affected than those meeting only DSM-IV criteria. Factor analysis indicated that the LP criterion loading is the lowest of all symptoms; IRT analysis suggested that this criterion has low discriminatory power. The genetic correlation between DSM-IV and DSM-5 diagnoses was slightly but significantly lower than unity.
!!Conclusions
The proposed DSM-5 AUD criteria are unlikely to result in significant changes in prevalence of diagnosed alcohol problems. However, it is unclear whether the new criteria represent a more valid diagnosis: new cases are no more severely affected than DSM-IV-only cases. Given the psychometric properties of LP, its exclusion should not negatively impact diagnostic validity. Similarly, the stable heritability across DSM-IV and DSM-5 diagnoses suggests that the proposed changes will not have substantial negative consequences in terms of familial influences, a key validator. These results provide equivocal empirical support for the proposed DSM-5 changes for AUDs.

__FAMILY BEHAVIOUR THERAPY__
Trialled Vs Gp Counselling in Azrin et al 1994 - small sample size (29) and no long term follow up, no clinically signif change)
an intervention that addresses adolescent
drug use and associated behavioral problems (Donohue
& Azrin, 2001). As the name implies, FBT is based on a
behavioral conceptualization of substance use and the
development of substance use problems, whereby drug
use is considered a strong primary reinforcer, as it is reinforced
by both physiological stimuli (i.e., dependence,
tolerance) and situational stimuli (i.e., peer acceptance,
stress).
The FBT approach uses multiple empirically validated
techniques with an emphasis on contingency management
and communication skills training to target multiple
domains of functioning: drug use, conduct, problem-solving skills, family interactions, and communication
skills. Standardized components of this program include
the following: pretreatment engagement strategies, an
assessment with the adolescent and the parents, drug
analysis, dissemination of assessment and drug analysis
results to the youth and parents, intervention selection by
youth and family, and implementation of the selected
interventions. In further efforts to affect multiple domains
of adolescent functioning, adolescents in FBT are
encouraged to involve siblings and peers in the therapy
process. Although FBT is a standardized program, it is
designed to accommodate a diverse population of youths
with a variety of cultural, behavioral, and individual preferences.
In the FBT program, youths and families are able
to select from a list of intervention strategies, those
strategies that will best meet their individual needs.

See [[Waldron et al 2001]]
FFT is based, in large part, on
family systems theory, which assumes that problem
behaviors occur in the context of family relationships and
serve some core function within these family relationships.
In addition to a family systems perspective, the
FFT model relies heavily on cognitive behavioral theory
and techniques. FFT takes a multisystemic approach to
intervention by focusing on the multiple domains and
systems in which the adolescent lives.
The intervention process in the FFT model is divided
into two primary phases: (a) engagement and motivation
of the youth and family and (b) behavior change for the
youth and family. For substance-abusing youths, the main
objectives of treatment are to (a) reduce or eliminate
problematic substance use, (b) reduce or eliminate other
problem behaviors within the family, and (c) improve
family relationships. Therapeutic efforts in the FFT
model are aimed at identifying the functions served by
substance use and helping the youth and family replace
maladaptive behaviors (substance use and other problem
behaviors) with safer, more adaptive behaviors.

The family support network (FSN) (Hamilton
et al
.
2001) provides additional support for families (home visits,
parent education meetings and case management services).
This multi-component treatment reflects many of
the values promoted in CSAT’s (1992a,b) treatment
improvement protocol on adolescent treatment (e.g.
family-centered approach, provision of case management,
home-based services). FSN services are designed to
be wrapped around an existing individual or group treatment,
in this case MET/CBT5 + CBT7.

COCHRANE COLLAB on Opiate Addiction
Adult study:
conclusions important:
Higher dosage maintenance is more effective.
Methadone dosages ranging from 60 to 100 mg/day are more effective than lower dosages in retaining patients and in reducing use
of heroin and cocaine during treatment. To find the optimal dose is a clinical ability, but clinician must consider these conclusions in treatment strategies.
"identified 21 controlled trials involving a total of 5994 opioid users. In 11 of these trials, all from the USA, 2279 participants were randomised to methadone treatment at different doses or another treatment (buprenorphine or levomethadyl). Treatment was for between seven and 53 weeks. A further 10 controlled trials did not randomly assign the total of 3715 participants to a treatment. These were from various diverse countries and followed opioid users for one to 10 years. Higher doses of methadone (60 to 100 mg/day) were more effective than lower doses (1 to 39 mg/day) in retaining opioid users in therapy and in reducing illicit use of heroin and cocaine during treatment. Side effects of methadone appeared to be similar at the different doses, in one trial only."

Motivational Interviewing with Underage College Drinkers: A Preliminary Look at the Role of Empathy and Alliance
55 underage heavy drinkers, aged 18 - 20 yrs recruited from psychology classes at public university in southwest States. Offered course credit (?) in return for particiaption.
Approx 3/4 were female. N= 65 (after screening 136) anglo 63% Hisp 21% + others
RCT - 1 session MI, Vs no-Rx control
Used Monitoring Future Q's for bingeing and the RAPI questionnaire (validated) for SU,
and
the MITI for ''therapist empathy''
WAI (Working Alliance Inventory) for ''pt-therapist alliance''
51/65 followed up
Significant main effects for ''time'' (both conditions showed improvements over time, but not for group effects...
Effect sizes (Cohen’s d ) and confidence intervals indicated that the
MI condition outperformed the control condition for both binge drinking
(d= -0.49) and alcohol-related problems (d = -0.21).
MI signif reduced binge drinking and alochol related problems compared to No Rx
''ALLIANCE bore no signif relation to outcomes'' (tho low power in the MANOVA used to analyse this)
''EMPATHY no signif relations found to outcomes'' but low variability in this measure as all therapists scored highly.

Aripiprazole Blocks Reinstatement of Cocaine Seeking in an Animal Model of Relapse .
Biological Psychiatry 2007, Volume 61 , Issue 5 , Pages 582 - 590 M . Feltenstein , C . Altar , R ....
@@experimental model@@
Abstract
Background
Aripiprazole (Abilify) is an atypical antipsychotic drug primarily characterized by partial agonist activity at dopamine (DA) D2 receptors and low side effects. Based on pharmacologic properties that include a stabilization of mesocorticolimbic DA activity, a pathway implicated in addiction, aripiprazole was tested for its ability to prevent relapse to cocaine seeking in rats.
Methods
We assessed the dose-dependent effects of aripiprazole on conditioned cue-induced and cocaine-primed reinstatement of drug-seeking behavior following chronic intravenous cocaine self-administration in an animal model of relapse.
Results
Aripiprazole potently and dose-dependently attenuated responding on the previously cocaine-paired lever during both reinstatement conditions, with slightly greater efficacy at reducing conditioned-cued reinstatement. Aripiprazole was effective at doses that failed to alter cocaine self-administration, food self-administration, reinstatement of food-seeking behavior, or basal locomotor activity, suggesting selective effects of aripiprazole on motivated drug-seeking behavior.
Conclusions
These results in a relapse model show that aripiprazole can block cocaine seeking without affecting other behaviors. The D2 partial agonist properties of aripiprazole likely account for the blockade of reinstatement of cocaine-seeking behavior. Given its established efficacy and tolerability as a treatment for psychosis, aripiprazole may be an excellent therapeutic choice for reducing craving and preventing relapse in people with cocaine dependency.

Cochrane review of PRIMARY PREVENTATIVE STUDIES
D. R. Foxcroft, D. Ireland, D. J. Lister-Sharp, G. Lowe, R. Breen (2003) Longer-term primary prevention for alcohol misuse in young people: a systematic review Addiction 98 (4) , 397–411
Abstract
''Objective'':
To identify and summarize rigorous evaluations of psychosocial and educational interventions aimed at the primary prevention of alcohol misuse by young people aged up to 25 years, especially over the longer term (>3 years).
''Methods'':
Cochrane Collaboration Systematic Review.
''Data sources'':
A comprehensive search of 22 databases and recursive checking of bibliographies for randomized and non-randomized controlled trials and interrupted time-series studies.
''Main outcome measures'':
Objective or self-report measures of alcohol use and misuse.
''Results''
Fifty-six studies were selected for inclusion in the systematic review.
• Twenty of the 56 studies showed evidence of ineffectiveness.
• No firm conclusions about the effectiveness of prevention interventions in the short- and medium term were possible.
• Over the longer term (>3 years), the ''Strengthening Families Programme'' (SFP) showed promise as an effective prevention intervention. The ''Number Needed to Treat'' (NNT) for the SFP over 4 years for three alcohol initiation behaviours (alcohol use, alcohol use without permission and first drunkenness) was ''9'' (for all three behaviours).
• One study also highlighted the potential value of culturally focused skills training over the longer-term (NNT = 17 over 3.5 years for 4+ drinks in the last week)
''Conclusions''
(1) Research into important outcome variables needs to be undertaken;
(2) the methodology of evaluations needs to be improved;
(3) the SFP needs to be evaluated on a larger scale and in different settings;
(4) culturally focused interventions require further development and rigorous evaluation; and
(5) an international register of alcohol and drug misuse prevention interventions should be established and criteria agreed for rating prevention interventions in terms of safety, efficacy and effectiveness.

Journal of Adolescent Research, Vol. 16, No. 6, 661-678 (2001)
Prospective Risk Factors and Treatment Outcomes among Adolescents in DATOS-A
Galaif, Hser, Grella, Joshi.
@@(From [[Hser et al 2001]]:
"the first large-scale effort designed specifically to evaluate treatment outcomes among adolescents. Treatment programs included in DATOS-A were community programs specifically intended to treat adolescents with drug problems. This article reports results of an assessment of treatment outcomes among adolescent patients participating in DATOS-A. The study addressed 3 key research questions:
(1) What were the patterns of drug use and other problem behaviors of these adolescents before they entered the DATOS-A treatment programs?
(2) Were there changes in their drug use and other problem behaviors after treatment?
(3) Was the length of stay in treatment related to their posttreatment outcomes?@@
The relationships between risk factors and outcomes in adolescents participating in the Drug Abuse Treatment Outcome Studies for Adolescents (DATOS-A) were examined.
The study included 292 admissions to nine ''outpatient drug-free (ODF)'' and 418 admissions to eight ''residential (RES)'' programs.
Assessments were administered at intake into treatment and 12 months following discharge.
For ''ODF participants'',
(a) severity of drug use predicted less retention in treatment, and
(b) family drug involvement predicted more alcohol use after treatment.
''For RES participants'',
(a) family drug involvement and criminal involvement predicted less treatment retention, and
(b) conduct disorder predicted more marijuana use at follow-up.
The findings underscore the need for intervention strategies that address
#the intrapsychic and
#interpersonal functioning
of drug-abusing adolescents to improve their behavioral outcomes.

Short-term outcomes after brief ambulatory opioid detoxification with buprenorphine in young heroin users
Devang H. Gandhi, Jerome H. Jaffe, Scot McNary, Greg J. Kavanagh, Michael Hayes, Marian Currens
Addiction, 98, 453–462
Prospective follow up study
123 participants with an average age of 21.8 years (SD 2.1) enrolled in the study. (Aged 18 - 25)
69 (56.1%) were male, 117 (95.1%) were white.
@@No control group or comparison group@@
Private clinic with walk in facility - payment by insurance or a one-off payment for the whole detox - @@but a very 'cheap and cheerful set up'@@ - "the clinic where this study was conducted offered the treatment at a total cost of less than $200 to self-paying patients during the study period."
Brief ambulatory detox using buprenorphine
"''assigned randomly'' to receive either of two buprenorphine dose schedules:
#the ‘standard’ dose of 2 mg sublingual (SL) tablet or 0.3 mg
intramuscular (i.m.) injection; and
#a ‘high’ dose of 4 mg SL or 0.6 mg i.m. injection.
The ‘standard’ dose represented the usual dose of buprenorphine offered by the
clinic to all patients. @@Patients were not blind to their dose@@
of buprenorphine, but generally were not told the dose.
Early in the study, it became apparent that the route of
administration was a major concern of the participants.
Patients expressed a strong preference for the sublingual
tablet rather than the intramuscular injection, based on
the perception that the sublingual tablet would ‘hold’
them longer."
"Patients were allowed to receive buprenorphine up to twice a day, but the second
administration of the day was no more than the ‘standard’
(0.3 mg i.m. or 2 mg SL) dose. Patients were also
given additional medications for specific symptoms that
were used ordinarily as a part of the detoxification program.
The medications that could be administered for the
length of treatment included ibuprofen for pain, doxepine
for sleep/anxiety, cyclobenzaprine for muscle spasms, loperamide
for diarrhea and clonidine for high blood pressure.
Patients could continue to receive symptomatic
medications as long as required to control withdrawal
symptoms, but had to attend the clinic daily to receive
them."
Variety of validated insruments for follow up - and urinalysis.
Payments ($10 for telephone, $25 for face to face) for FOLLOW ups
"Retention in detoxification was very high (96%) as
long as buprenorphine was administered, i.e. the first 3
days. After this, there was a rapid decline in attendance,
with half the patients dropping out over the next 3 days,
and all the patients by the 10th day" - @@very high drop out rates!!!@@
@@Poor follow up capture of subjects:@@
at 1/12 interviewed 95/119 (79.8%)
at 3/12 interviewed 65/119 (54.6%)
at 6/12 interviewed 56/119 (47.1%)
RESULTS:
Using the total number of patients eligible for followup (119) as the denominator @@(‘intent-to-treat’ analysis)@@, ''6.7%, 10.1% and 11.8% of the subjects reported abstinence from heroin use at 1, 3 and 6 months, respectively,'' and were also able to provide a negative urine drug test to confirm their self-report. However, as all the subjects followed-up at each time point were not tested, this provides the most conservative estimate of non-use.
Self report showed much higher rates of success:
"No use or diminished use was reported by 75/119 (63.0%) at 1 month, 56/119 (47.1%) at 3 months and 49/119 (41.2%) at 6 months."
High rates of treatment satisfaction majority of the respondents (63/91, 70.3%) reported the experience as ‘good’ or excellent’ and 93.4% (85/91) rated it at least as ‘somewhat useful’. Eighty-two (90.1%) said they would go through detoxification again. Most (77/93, 82.8%) had not enrolled in an aftercare program at 30 days (variation in the number of respondents is due to some patients not responding to all the questions).
(strong prefernce for sub-lingual Vs injected buprenorphine, too)
''@@LEGISLATION EFFECTS@@''
"A major hurdle in improving outcomes of outpatient
opioid detoxification in the United States has been @@the
Federal restriction on the use of opioid medications, limiting
their use in the treatment of addiction to 3 days in
most settings.@@ Under the Drug Addiction Treatment Act
of 2000, the rules governing the use of buprenorphine for
the treatment of addiction will change because it is now
approved for this indication by the Food and Drug
Administration, allowing its use for detoxification or
maintenance in physicians’ office-based practice."

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Alcohol (and CBS)
Mean 15.7yr old offenders -
brief mixed Motivational + CBT = "Guided Self Change" (GSC) -
Part of the "ATTAIN" programme (Alcohol Treatment Targetting Adoelscents In Need)
….with CULTURALLY SENSITIVE aspects - in Hispanic and African American youth… in clinics placed LOCALLY to where patients lived.
Treatment streams
(a) Individual
(b) Family-involved
(c) choice of either a or b
(d) Wait list control
!!ALSO looking at CultureEthnicity
(a) the effect of perceived discrimination/cultural mistrust in African americans affects rates of SUD,
(b) correltaions between acculturation and lower levels SUD/better response to Rx and between Acculturative stress and higher levels of SUD/worse response to Rx. in the Hispanic population.
214 juvenile offenders with SUD mean age 15.7
128 US-born Hispanics, 45 foreign-born Hispanics and 40 African Americans.
90.9% male and 9.1% female. 90
Part of lage treatment trial ATTAIN
"Assessments are completed at:
baseline, post-intervention and 3-, 6- and 9-month follow-ups.
Timeline Feedack interview (TLFB) to measure alc, CBS use.
Broadly validated scales for cultural questions (acculturation, racial mistrust, etc)"
RESULTS
"reductions in all groups from baseline use of alc of about 70% of days down to 30% in african americans (best response) and for CBS from 80-90% of days down to between 40-49% of days.
Among the US-born Hispanics, three variables were related to several of the baseline measures:
#Perceived discrimination and acculturation
were related positively to number of drugs used,
i.e. clients who were more acculturated and reported
higher levels of perceived discrimination also reported
higher levels of AOD use.
#Acculturation also was related
positively to marijuana use (against the previous research that suggests lower drug use in 1st generation 'new arrivals' compared to 2nd generation immigrnats).
#In contrast, ethnic pride was correlated negatively with marijuana use; that is, clients who reported greater ethnic pride reported lower levels of
marijuana use.
Both ethnic orientation and ethnic pride appear to be protective factors for drug and alcohol use among African
Americans. African American youth with greater ethnic pride and ethnic orientation are more likely to recognize or acknowledge
substance use problems and the need for substance use treatment.
Multiple regressionanalyses to look at relationships between these fators and Rx outcomes in Hispanics (not enough African americans to do this) show:
Hispanic youth with
#greater Hispanic cultural orientation and
#greater ethnic pride responded better to treatment by having greater reductions in use."

Preliminary outcomes from the assertive continuing care experiment for
adolescents discharged from residential treatment
Mark D. Godley, Ph.D.*, Susan H. Godley, Rh.D., Michael L. Dennis, Ph.D.,
Rodney Funk, B.S., Lora L. Passetti, M.S.
Journal of Substance Abuse Treatment 23 (2002) 21–32
see follow up paper [[Godley et al 2007]]
!''Definition of CRA for adoelscents:''
An intervention that includes many of the features recommended
for continuing care intervention is the Community
Reinforcement Approach (CRA) (Azrin, Sisson, Meyers,
& Godley, 1982; Meyers & Smith, 1995). CRA is a behavioral
intervention that helps clients restructure their environment
with prosocial activities that compete against
continued substance use. In addition, CRA examines the
relationship between using behavior and other behaviors and
teaches the client skills to improve daily communication and
problem solving as well as overcoming resistance and
obstacles to participating in prosocial activities. Over the
past 30 years, CRA has proven effective in several outpatient
clinical trials with adult alcoholics and other drug abusers
(Miller, Meyers, & Hiller-Sturmhofel, 1999). Although
untested as a continuing care strategy for adolescents, it is
well-suited to follow residential treatment and was, in fact,
used this way in its first two trials with adults (Azrin, 1976;
Hunt & Azrin, 1973). The present study seeks to augment
CRA with a component designed to assist the caregivers and
improve problem solving and communication between caregivers
and the client. In addition, since adolescent clients are
frequently involved in the education, criminal justice, mental
health and/or child welfare service systems, the addition of
case management services (Godley, Godley, Pratt, & Wallace,
1994) was deemed necessary to help them access and
negotiate complex services systems.
Quote from Godley et al 2007 summarising their findings here:
"Early findings from this 5-year study showed
that an assertive service delivery protocol using ''home
visits'', ''case management'' [21] and the ''community reinforcement
approach'' [[ACRA]] [35–39] was significantly more likely
than the usual continuing care (UCC) condition to
link participants to assertive continuing care (ACC),
despite the fact that almost half the participants in both
conditions had unplanned discharges from residential
treatment. Outcomes at the end of the 3-month continuing
care phase showed that a significantly greater
proportion of ACC participants remained abstinent from
marijuana compared to the UCC condition. Results for
alcohol abstinence were marginally significant."

Thirty-month relapse trajectory cluster groups among
adolescents discharged from out-patient treatment
Susan H. Godley, Michael L. Dennis, Mark D. Godley & Rodney R. Funk
analysis of CYT data - interesting but not a Rx study... only 2star
looking at clustering in long term trajectories
Identifies 4 main trajectory groups over 30 months post Rx:
Adolescents can be grouped empirically into five relapse trajectories over 30/12 post Rx:
''(a) low AOD use with limited days in a controlled environment;''
The low-AOD use, low-CE group had the highest proportion of females and Caucasians, the lowest proportion reporting weekly
cannabis use during the 90 days preceding the intake interview, and the highest proportion (although not significant) who completed treatment successfully.
''(b) low AOD use with high days in a controlled environment;''
had the highest proportion of males and almost twice as many African Americans as any other group. It also had the highest proportion in the lowest educational attainment category (5th- to 8th-grade education), from single- parent households and involved in the criminal justice system. Even though this group had the highest days in a controlled environment, it had the lowest percentage of adolescents who endorsed symptoms of conduct disorder, as well as ADHD and depression..
''(c) moderate/decreasing AOD use;''
had the highest proportion of older adolescents (15–18), although the two groups with the poorest trajectories also had higher proportions of older adolescents than the two low AOD use groups. The moderate and decreasing AOD group had the second lowest proportion reporting major depression disorder symptoms and the second highest proportion reporting symptoms of conduct disorder.
''(d) increasing AOD use;''
along with the //low AOD use, low CE// group this group had the highest proportions of adolescents reporting major depression disorder. Although not significantly different, it also had the highest proportions reporting symptoms of other (besides cannabis) drug dependence at intake and prior mental health treatment.
''(e) consistently high AOD use.''
had the highest proportion of individuals who reported using any alcohol, weekly alcohol use and very high blood alcohol content levels. This group also had the highest proportion of adolescents reporting symptoms for ADHD and conduct disorder.

The effect of assertive continuing care on continuing care linkage, adherence and abstinence following residential treatment for adolescents with substance use disorders
Mark D. Godley, Susan H. Godley, Michael L. Dennis, Rodney R. Funk & Lora L. Passetti (Chestnut Health Systems)
Addiction, 102, 81–93 (2007)
Follow on from preliminary findings paper ([[Godley et al 2002]])
5Star as good research paper and important results.
!''RATIONALE:''
The study followed from recent theoretical evidence that an early period of ''sustained abstinence straight after treatment - during outpatient follow up, may be linked to successful long term outcomes''...
Quote Godley et al:
"In two studies of adults who were primarily
dependent on cocaine and alcohol, retention in outpatient
treatment and reduced use were not sufficient to
predict long-termabstinence outcomes; only those with a
period of sustained abstinence during (outpatient) treatment
experienced sustained post-treatment abstinence
@@[(a) Higgins S. T., Badger G. J., Budney A. J. Initial abstinence
and success in achieving longer-term cocaine abstinence.
Exp Clin Psychopharmacol 2000; 8: 377–86, and
(b)Kosten T. R., Gawin F. H., Kosten T. A., Morgan C., Rounsaville
B. J., Shottenfeld R. et al. Six-month follow-up of
short-term pharmacotherapy for cocaine dependence. Am J
Addict 1992; 1: 40–9.]@@.
While the experimental approaches may have
been more effective at retention and moving participants
to early abstinence, ''it was whether the actual early
sustained abstinence response (regardless of condition)
was obtained that predicted long-term abstinence''. This
finding suggests that the impact of treatment was mediated
by the early response to treatment, that multiple
types of treatment could produce this response and that it
was the ‘early treatment response’ that served as the key
to subsequent sustained abstinence."
@@DB: I.e. Many treatments may be able to get a patient to the point of abstinence early on in treatment, but the deciding factor regarding //long term benefit// seems to be the capcity of the treatment then to respond to and support this early abstinence...@@
There is plenty of evidence that YP in in-opt treatment frequently fail to engage with local OP follow up.
!''PURPOSE:''
"(1) to update results reported in the preliminary findings paper [[Godley et al 2002]] on the effect of ACC in linking and retaining adolescents in postresidential continuing care and its effect on abstinence outcomes;
(2) to extend the understanding of more effective continuing care in general, and ACC in particular, by examining
(a) its ability to increase a measure of ''general continuing care adherence (GCCA)'' (a set of 12 scales by which adherence could be measured (Such as such as "attending weekly meetings", "regular urine tests" receiving "problem solving" component of care, etc,.. 7/12 of these criteria denoted "High Adherence");
(b) the extent to which continuing care adherence (from UCC and ACC) predicts early abstinence; and
(c) the extent to which early abstinence then predicts longerterm abstinence outcomes.
Thus, the analyses assume that ACC has a direct effect on GCCA and indirect effects on early abstinence (via GCCA) and sustained abstinence (via GCCA and early abstinence)."
!''DESIGN:''
''2-group randomized design'' - for 183 discharged (in-patient) treated adolescents (12 - 17yrs) with SUD (DSM IV), who had met ASAM (American Society for Addiction Medicine) criteria for in-pt treatment. situated in Mid West of US.
Random allocation (Randmised Block design) into two groups:
''ACC (Assertive Community Care, with ACRA, n= 102) Vs. UCC (Usual Community care, n=81)''
No statistical diffs between these two groups.
In-pt stay - Average Length of stay = 52 days, 51% and 53% (UCC and ACC)had "as planned discharges (no stat differences)
UCC - referred as usual to a wide range of local outpatient services - no attmept to modify this (TAU) - varying rates of effort in linking to Op follow up - less if discharge sudden or against advice (got a letter and direnctions) - if planned got an appt date usually c. 2/52 from D/c date.
ACC - same onwards referrals, BUT ALSO:
#ACC case manager for 90 days post disch, whose role was
##Linking to services
##Meet weekly with YP and/or carers throughout 90 days and help them link up w/ services
##Encourage prosocial activities, new friendship groups
#Home visits
2 Manuals for Case Managers - one for Case Management and one for [[ACRA]]
TReatment Fidelity - audiotapes, observations, training supervision
Multiple Outcome measiures - GAIN and GCCA (imbeddd within this)
!''RESULTS'':
Generaly ACC cases showed significnatly better adherence and ''more 'high GCCA' '' (above the median of seven criteria (see above) being met) than the equivalent UCC cases - (64% ACC were 'high GCCA' versus 35% UCC). The ''odds of having high GCCA were three times higher (OR = 3.35, P < 0.05) for adolescents in the ACC group than those in the UCC condition.''
''This translated into higher rates of ABSTINENCE:''
"Abstinence rates were more than 20% higher for ACC in five of six comparisons;
however, the size of the difference reached ''statistical significance'' in only the comparison for sustained marijuana abstinence [Abstinence for 9/12, the most frequently used substance.
As shown , a primary problem with this contrast is power." - @@DB: the numbers of users of other drugs were too small to demonstrate statistical signif in the effects upon their use, although trends suggest similar...@@
CBS abstinence for 9 months : UCC=26%; ACC=41%; Increase with ACC=59%; Effect size (Cohen's) d = 0.32, Chi squared = 4.45 p< 0.04 Power=56%
DB- Further analyses suggest (''though without the statistical power to prove it'') that the effect of ACC may be mediated via its ability to foster high GCCA, and the subsequent association between high GCCA and early abstinence...
but high GCCA is no guarantee of abstinence: "Even among those adolescents who had high values on the GCCA scale, 57% relapsed during the subsequent 6 months."
And while ''ACC was associated with incr abstinence up to 9 months'' SO ALSO was ''the WITHDRAWAL OF ACC at the end of month 3 associated "with a non-significnat trend towards increased relapse in months 4 through 9"''... i.e 'hold them up too firmly and they stumble when you let them go' - the authors argue for more flexible ongoing follow up contingent on the patients actual level of fucntioning (fits with the the cronic illness model, I suppose - balanced against the cost and 'stigma' arguments for getting in and out with our treatments quickly...)

Seems to follow trials evidence from [[CYT]]
!Author:
S. H. Godley, B. R. Garner, L. L. Passetti, R. R. Funk, M. L. Dennis and M. D. Godley
!Year:
2010
!Title:
Adolescent outpatient treatment and continuing care: Main findings from a randomized clinical trial
!Journal: Drug and Alcohol Dependence
Volume: 110 Issue: 1-2 Pages: 44-54
!!Abstract:
This study evaluated the effectiveness and cost-effectiveness of two types of outpatient treatment with and without Assertive Continuing Care (ACC) for 320 adolescents with substance use disorders. Study participants were ''randomly assigned'' to one of four conditions:
(a) Chestnut's Bloomington Outpatient Treatment (CBOP) without ACC;
(b) CBOP with ACC;
(c) Motivational Enhancement Therapy/Cognitive Behavior Therapy-7 session model (MET/CBT7) without ACC; and
(d) MET/CBT7 with ACC.
All study conditions attained high rates of participant engagement and retention.
Follow-up interviews were completed with over 90% of the adolescents at three, six, nine, and 12 months after treatment admission.
There was a significant time by condition effect over 12 months, with CBOP having a slight advantage for average percentage of days abstinent.
''//Unlike previous findings that ACC provided incremental effectiveness following residential treatment, there were no statistically significant findings with regard to the incremental effectiveness of ACC following outpatient treatment.//''
Analysis of the costs of each intervention combined with its outcomes revealed that the most cost-effective condition was MET/CBT7 //without ACC//

S.H. Godley, B.R. Garner, L.L. Passetti, R.R. Funk, M.L. Dennis, and
M.D. Godley (2010) Adolescent Outpatient Treatment and Continuing Care: Main Findings from a Randomized Clinical Trial. Drug Alcohol Depend. 110(1-2): 44–54.
!Abstract
This study evaluated the effectiveness and cost-effectiveness of two types of outpatient treatment with and without Assertive Continuing Care (ACC) for 320 adolescents with substance use disorders.
Study participants were randomly assigned to one of four conditions: (a) Chestnut’s Bloomington Outpatient Treatment (CBOP) without ACC; (b) CBOP with ACC; (c) Motivational Enhancement Therapy/Cognitive Behavior Therapy-7 session model (MET/~CBT7) without ACC; and (d) MET/~CBT7 with ACC. All study conditions attained high rates of participant engagement and retention.
Follow-up interviews were completed with over 90% of the adolescents at three, six, nine, and twelve months after treatment admission. There was a significant time by condition effect over 12 months, with CBOP having a slight advantage for average percentage of days abstinent.
Unlike previous findings that ACC provided incremental effectiveness following residential treatment, there were no statistically significant findings with regard to the incremental effectiveness of ACC following outpatient treatment. Analysis of the costs of each intervention combined with its outcomes revealed that ''the most cost-effective condition was MET/~CBT7 without ACC''.

Bridget F. Grant, Frederick S. Stinson, and Thomas C. Harford, (2001) Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: A 12-year follow-up. Journal of Substance Abuse Volume 13, Issue 4, December 2001, Pages 493-504
Indications that ''rates of adult alcohol dependence can be reduced by 10% for each year that drinking is delayed in adolescence…''
5star because v relevant paper - should be quoted in intro to alcohol study.
Abstract
Purpose:
The purpose of this study was to examine the relationship between age at drinking onset and the development of DSM-IV alcohol abuse and dependence in a 12-year prospective study of youth in the United States.
Methods:
Logistic regression analyses were used to quantify the relationship between age at drinking onset and the development of alcohol abuse and dependence controlling for sociodemographic factors and problem indicators.
Results:
The odds of alcohol dependence decreased by 5% in 1989 and 9.0% in 1994 for each year drinking onset was delayed. In 1994, the odds of alcohol abuse increased by 7.0% with each decreasing year of age at drinking onset, while age at drinking onset was not related to alcohol abuse in 1989.
Several other risk factors were found to be strong and consistent predictors of abuse and dependence in 1989 and 1994, including being male, divorced, separated or never married, younger, and having an early history antisocial behaviors and marijuana use.
Implications: Implications of the results of this study are discussed in terms of other factors that may impact on the onset-abuse and onset-dependence relationship and the need to focus future prevention efforts.

J Nerv Ment Dis. 2001 Jun;189(6):384-92.
Drug treatment outcomes for adolescents with comorbid mental and substance use disorders.
Grella CE, Hser YI, Joshi V, Rounds-Bryant J.
See also [[Hser et al 2001]]
UCLA Drug Abuse Research Center, Neuropsychiatric Institute, University of California, Los Angeles 90025, USA.
This study compared the pretreatment characteristics and posttreatment outcomes of substance-abusing adolescents with and without comorbid mental disorders in the Drug Abuse Treatment Outcome Studies for Adolescents. Subjects (N = 992) were sampled from 23 adolescent drug treatment programs across three modalities (residential, short-term inpatient, outpatient drug-free). Nearly two thirds (64%) of the sample had at least one comorbid mental disorder, most often conduct disorder. Comorbid youth were more likely to be drug or alcohol dependent and had more problems with family, school, and criminal involvement. Although comorbid youth reduced their drug use and other problem behaviors after treatment, they were more likely to use marijuana and hallucinogens, and to engage in illegal acts in the 12 months after treatment, as compared with the noncomorbid adolescents. @@Integrated treatment protocols need to be implemented within drug treatment programs in order to improve the outcomes of adolescents with comorbid substance use and mental disorders.@@

@@DB - There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers.@@
Authors' conclusions
''Complex approaches show promise'', with some persistence of abstinence (30 days point prevalence abstinence at six months), ''especially those incorporating elements sensitive to stage of change''.
''pharmacology'': There were few trials with evidence about pharmacological interventions (nicotine replacement and bupropion), and none demonstrated effectiveness for adolescent smokers.
''Psycho-social'' interventions have not so far demonstrated effectiveness, although pooled results for the Not on Tobacco trials suggest that that this approach may yet prove to be effective; however, their definition of cessation (one or more smoke-free days) may not adequately account for the episodic nature of much adolescent smoking.
There is a need for well-designed adequately powered randomized controlled trials for this population of smokers, with a minimum of six months follow up and rigorous definitions of cessation (sustained and biochemically verified). Attrition and losses to follow up are particularly problematic in trials for young smokers, and need to be kept to a minimum, so that management and interpretation of missing data need not compromise the findings.
We identified 15 good quality studies (3605 participants) that researched ways of helping teenagers to quit. Complex programmes, including those tailored to the young person's preparation for quitting, and behavioural therapy programmes show some promise. However, the number of trials and participants do not yet provide enough evidence to judge effectiveness. Medications such as nicotine replacement and bupropion have not yet been sufficiently tested in adolescents. Trials used different definitions of quitting and many smaller trials did not have enough participants for us to be confident about wider application of the results. Some approaches may be worthy of consideration but there is still a need to provide better evidence before large scale investment in programmes.
''Implications for practice''
Research is at an early stage and no study has tackled sustained quitting. Those interventions with positive outcomes, in terms of their own protocols, are complex and are designed to respond to the many issues that characterise young persons' smoking. In particular complex approaches show promise and show some persistence of abstinence (30 days PPA) but there is not as yet sufficient evidence to recomend widspread implementation of any one model. It would also appear that the Not on Tobacco programme is at least as effective as other interventions, but a major issue for this programme is that the meaningfulness of the definition of cessation (one day or more) must be challenged when compared to the episodic nature of patterns of smoking of young people.
There is currently little evidence on effective regimens of pharmacotherapies or incorporation of NRT into psychosocial programmes in this age group. The evidence does not support the use of bupropion as an adjunct to NRT. There is no evidence regarding the use of bupropion alone. Evidence from one study suggests intervention with those caught in violation of school smoking cessation policies is ineffective. In view of the paucity of the evidence services need to be rigorously evaluated in terms of outcomes.
Practitioners need to be aware of the developing evidence base and be prepared to modify services accordingly. Barriers to implementation of the research studies, even when strategies can be shown to be effective, should be considered by those who develop services, as many of the issues did not arise simply from research protocols but from the practicalities of working with organisations and young people (Kishnuck 2004; Grimshaw 2003).

Hallfors, D. (2006). Efficacy vs effectiveness trial results of an indicated "model" substance abuse program: implications for public health.
OBJECTIVES: The US Department of Education requires schools to choose substance abuse and violence prevention programs that meet standards of effectiveness. The Substance Abuse and Mental Health Services Agency certifies "model" programs that meet this standard. We compared findings from a large, multisite effectiveness trial of 1 model program to its efficacy trial findings, upon which the certification was based.
METHODS: 1370 high-risk youths were randomized to experimental or control groups across 9 high schools in 2 large urban school districts. We used intent-to-treat and on-treatment approaches to examine baseline equivalence, attrition, and group differences in outcomes at the end of the program and at a 6-month follow-up.
RESULTS: Positive efficacy trial findings were not replicated in the effectiveness trial. All main effects were either null or worse for the experimental than for the control group.
CONCLUSIONS: ''These findings suggest that small efficacy trials conducted by developers provide insufficient evidence of effectiveness. Federal agencies and public health scientists must work together to raise the standards of evidence and ensure that data from new trials are incorporated into ongoing assessments of program effects''

A school-based harm minimization smoking
intervention trial: outcome results Addiction, 100, 689–700
Harm minimisation intervention ("Keep Left" - play on traffic safety advice cf a scale of risk rsing from left to right)
4 year cluster randomised trial
4636 students (number required baed on power studies) aged 13 - 14 yrs
in 30 W. Australian schools
The philosophy of harm minimization recognizes that
drug use is a natural phenomenon in free society (and
will continue to be so). Therefore, rather than attempting
to eradicate substance use, pragmatic efforts focus on
reducing the potential public health and social consequences
associated with use...
RESULTS
The harm minimization intervention implemented in this
trial resulted in reduced regular and 30-day smoking
among intervention students compared with those in
comparison schools. Over the 20-month trial period
intervention students were almost one-half as likely to
smoke regularly than comparison students. The intervention
effects on smoking in the previous 30 days were
more modest (OR = 0.69).
Effect size:
The effect size of these changes, 0.21 for regular smoking
and 0.19 for 30-day smoking, are similar to the weighted
effect sizes for school-based drug education programmes
reported by Tobler et al.’s [9] meta-analysis of 207 school
drug education programmes. Stronger effect sizes were
found for interactive programmes with weighted effect
sizes of 0.12 (all evaluations) and 0.14 (high quality evaluations)
for social influences programmes, 0.17 (both
categories) for comprehensive life skills programmes, and
0.27 and 0.22 for all evaluations and for high quality
evaluations, respectively, for system-wide change programmes [9].
Therefore, the intervention effect in this
study was greater than social influences and life skills
programmes, but less than programmes aiming to
achieve system-wide change.

Treatment of adolescent smokers with the nicotine patch
Karen Hanson, Sharon Allen, Sue Jensen, Dorothy Hatsukami
Nicotine & Tobacco Research Volume 5, Number 4 (August 2003) 515–526
"ABSTRACT:
This study examined the effects of the nicotine patch on craving and withdrawal symptoms, safety, and compliance
among adolescents. The secondary goal was to conduct a preliminary investigation of the effectiveness of the nicotine
patch in helping adolescents quit smoking.
@@The study design was a double-blind, placebo-controlled, randomized trial@@ of the nicotine patch. The intervention @@also provided intensive cognitive–behavioral therapy and a contingencymanagement procedure@@.
Participants (n~100) attended 10 treatment visits over 13 weeks.
Results:
Compared with the placebo patch group, the active nicotine patch group experienced
#a significantly lower craving score and overall withdrawal symptom score (p~.011 and p~.025, respectively)
#a time trend toward lower scores (pv.001)in craving only.
#Moreover, the nicotine patch appeared safe for adolescents to use. No differences by treatment group were found in experiencing adverse events, except that the participants in the placebo patch group reported more
headaches than those in the active nicotine patch group. As another measure of safety, the overall mean salivary
cotinine levels were significantly lower at 1, 6, 8, and 10 weeks postquit (all pv.05) compared with baseline levels,
although these results were confounded by dropouts.
#Additionally, a significant number of participants were compliant with using the nicotine patch daily.
#@@Finally, point prevalence (7-day and 30-day abstinence rates) and survival analysis of participant abstinence indicated no significant differences between treatment groups.@@
Conclusions:
The results of this study suggest that the nicotine patch is a promising medication and a larger clinical trial of the nicotine patch among adolescents is warranted."
Discussion in paper:
#NRT patches seem safe and well tolerated by adoelscents
#Fewer withdrawal signs and cravings reported ("participants in the active nicotine patch group who were abstinent also reported a significantly lower totalwithdrawal symptom score compared with those who were abstinent in the placebo patch
group.")
#Compliance with patch was high and 95.8% of study completers described patch as "helpful" or "very helpful" in their quit attempt.
#"although no differences between treatment groups were found with regard to abstinence rates, participants who did not quit reduced the number of cigarettes they smoked per day and CO levels by the end-of-treatment compared with baseline levels."
!DB notes:
1. Recruitment via flyers etc in schools - so @@a motivated cohort@@...
2. Dosing schedule:
"Participants who smoked >15 cigarettes per day were
assigned to the 21-mg system for 6 weeks, the 14-mg
system for 2 weeks, and the 7-mg system for 2 weeks.
Participants who smoked 10–14 cigarettes per day
were assigned to the 14-mg system for 6 weeks and the
7-mg system for 4 weeks."
3. Quite intensive input (confounding the effect of NRT with the intervention?):
"They met once during the first week, twice per week for the second week, once per week for the next 6 weeks, and biweekly for the final 4 weeks of treatment. The total study duration including the screening visit and orientation was 13
visits. @@Follow-up visits were conducted at 1- and 6-months posttreatment@@"
4. @@Cognitive behavioural interventions@@ at every visit to clinic:
"During each visit, participants received individual cognitive–
behavioral counseling provided by one counselor (KH).
The sessions lasted for about 10–15 min. During the
sessions, participants learned about topics such as
triggers for smoking, coping strategies including
action and thought responses, stress management,
and relapse prevention. Each session entailed information
that the counselor was required to cover"
5. In addition ContingencyMx was applied (tokens/points for biochemical markers pointing to abstinence):
"@@if participants were abstinent from cigarettes //throughout// the study, they received points and bonuses equivalent to US$125.00 in gift certificates.@@"
!Funding:
"This research was supported by National Institute on Drug Abuse
grant P50 DA09259 and the University of Minnesota Academic
Health Center. Statistical analyses were supported in part by National
Institutes of Health grant P50 DA13333."

!Conference 2012
Drug use is generally decreasing, and this is mainly INDEPENDENT of any legal interventions...
But kids who are drinking are drinking MORE...
Complex ecological factors underly drug use in youth...
!Co-occurring behaviours
If we intervene on underlying causes/behaviours/symptoms can this have impacts downstream on things like drug use?
!Evolutionary advantages in drives to intixication
Muller and Schumann, 2011 - drugs as "instrumental action" that may bring reproductive success...
!Complex road maps are theoretically possible
Mapping the full range of ecological elements that could be operated upon to make changes in adolescent substance use...
!Traditional responses
Just say no, here's an information sheet...
Woefully inadequate, and evidence of IATROGENIC effects... Boomerang response.
Eg FRANK
Few science based programmes, largely client/needs led...
Little EVIDENCE for effectiveness...
ACMD recommends we should rethink what we are doing...
!At a policy level prevention is always seen as Treatment's little brother
Effects of prevention is generally measured as Use of substances...
4% of NHS budget is spent on prevention (across the board of problems)... Is it surprising that it is so ineffective?!
Looking at prevention as having an impact on deterrence of progression rather than absolute non-behaviour...
!Prevention in INDICATED groups
Main risk factors:
* Male
* Peer and family history
* Pro substance norms
* Low school attachment
Etc...
!Promising programmes
!!!Preventure
[[Conrod et al 2006 (Alc)]]
!!!Strengthening Families
Based on resilience model
When adapted for European model, it loses it's effectiveness... Awaiting evidence.
!!!SHAHRP alcohol harm reduction
Developed in Australia mcbride Et al 2004
Sumnall Et al are doing big RCT over next 5 years...
!!!Good behaviour game
Classroom based primary schools-based... Setting norms around what is good behaviour....
Robust research in big RCTs with long term follow up... Kellem Et al, 2008.

"Motivational enhancement therapy for high-risk adolescent smokers" Addictive Behaviors 32 (2007) 2404–2410
47 Delinquent adolescents - arrested, offered court diversion - av age 16, started smoking at just before 12. Predom caucasian (84.4% MET Rx arm, 72.2% control - Educational package) No No-Rx Control.
TLFB, salivary cotinine, etc (part of a larger study)
Results initially (1/12 f/up) slightly better for Education RX than MET, but at 6/12 f/up this had reversed and MET slightly better results than Education (7 day abstinence self report: 5.2% for MET, 13.8% for Educn @ 1/12, and 11.9% for MET 11.1% for Educn @ 6/12, Salivary cotinine absitnence (< 15ng/mL) 10.5% for MET and 6.8% for Educn @ 1/12, and 9.5% for MET and 7.4% for Educn @ 6/12.
No significant Rx-Effects found
Multivariate analyses by ANOVA were conducted to examine the effect of other variables including ''concurrent alcohol use'' and measures of temperament known to predispose to risk of SUD (''~Sensation-seeking-Impulsivity (~SSImp)'')
In ''higher alcohol use MET actually peformed worse than Educn'', and in ''higher ~ImpSS MET performed worse than Educn'' - concusions that MET is no better than Educn (reading pamphlets), except for a subset of (lower risk) adoelscents ...tho better retention rates.
"These results are consistent with some recent work indicating that MET approaches may be less effective
with adolescents, particularly those with comorbid psychiatric problems (e.g., [[Brown et al 2003]])."
interesting paper - small numbers - links to another recent paper [[Brown et al 2003]]

!Author:
C. E. Henderson, G. A. Dakof, P. E. Greenbaum and H. A. Liddle (2010) Effectiveness of multidimensional family therapy with higher severity substance-abusing adolescents: report from two randomized controlled trials. Journal of Consulting & Clinical Psychology, 78, 6, 885-97.
!Year:
2010
!Title:
Effectiveness of multidimensional family therapy with higher severity substance-abusing adolescents: report from two randomized controlled trials ( [[Liddle, Dakof, Turner, Henderson, and Greenbaum (2008) - MDFT]] and [[Liddle et al - 2008 - MDFT for justice-involved youth]])
!Journal:
Journal of Consulting & Clinical Psychology, Volume: 78, Issue: 6, Pages: 885-97
!Abstract:
!!OBJECTIVE:
We used growth mixture modeling to examine heterogeneity in treatment response in a secondary analysis of 2 randomized controlled trials testing multidimensional family therapy (MDFT), an established evidence-based therapy for adolescent drug abuse and delinquency.
!!METHOD:
The first study compared 2 evidence-based adolescent substance abuse treatments: individually focused cognitive-behavioral therapy and MDFT in a sample of 224 urban, low-income, ethnic minority youths (average age = 15 years, 81% male, 72% African American). The second compared a cross-systems version of MDFT (MDFT-detention to community) with enhanced services as usual for 154 youths, also primarily urban and ethnic minority (average age = 15 years, 83% male, 61% African American, 22% Latino), who were incarcerated in detention facilities.
!!RESULTS:
In both studies, the analyses supported the distinctiveness of 2 classes of substance use severity, characterized primarily by adolescents with higher and lower initial severity; the higher severity class also had greater psychiatric comorbidity. In each study, the 2 treatments showed similar effects in the classes with lower severity/frequency of substance use and fewer comorbid diagnoses. Further, in both studies, MDFT was more effective for the classes with greater overall substance use severity and frequency and more comorbid diagnoses.
!!CONCLUSIONS:
Results indicate that for youths with more severe drug use and greater psychiatric comorbidity, MDFT produced superior treatment outcomes.

Juvenile drug courts: emerging outcomes and key research issues
Scott W. Henggeler
Review
NB conflict of interests as SH is on board of MST LTd....!
''Purpose of review''
In consideration of the widespread adoption of juvenile drug
court programs during the past decade, the purpose of this
review is to examine the effectiveness of juvenile drug
courts and suggest priorities for juvenile drug court
research.
''Recent findings''
Consistent with the much more extensive adult drug court
literature and the few uncontrolled evaluations of juvenile
drug court, findings from a recent randomized clinical trial ([[Henggeler et al 2006]])
suggest that juvenile drug court is more effective than family
court in decreasing participant criminal behavior and
substance use. Perhaps due to the intensive surveillance
that juvenile drug court participants receive, however, these
favorable outcomes did not translate to reduced rates of
rearrest or incarceration during the 12-month study period.
In addition, the integration of evidence-based substanceabuse
treatments into juvenile drug court enhanced
participant substance-related outcomes and rates of
juvenile drug court completion.
''Summary''
Although the widespread dissemination of juvenile drug
courts has exceeded clear and unambiguous evidence of
their effectiveness, few other criminal justice programs have
shown such promise with drug-abusing offenders.
Moreover, the integration of evidence-based treatments of
adolescent substance abuse holds the potential to further
enhance the effectiveness of juvenile drug courts.

Henggeler, S.W., Pickrel, S.G., & Brondino, M. J. (1999). ''Multisystemic
treatment of substance abusing and dependent delinquents:
Outcomes, treatment fidelity, and transportability''. Mental
Health Services Research, 1(3), 171-184.
reviewed by [[Austin et al 2005]]
"a sample of 118 juvenile offenders ages 12 to 17.
The sample consisted of primarily African American and
White youths (Table 2).
''Treatment retention was very high'', with 98% of youths in the MST condition completing the full course of treatment. Within the MST intervention, treatment length and intensity varied greatly among participants. In the reviewed study, treatment time ranged between 12 and 187 hours (M = 40 hours) for 3 to 6 months (M = 130 days).
''Outcomes'' were assessed for the following domains:
#treatment retention,
#drug and alcohol use,
#criminal activity, and
#out-of-home placements.
INCLUDED TREATMENT FIDELITY CHECKS
''Results'' indicated
#statistically significant decreases in reported drug and alcohol use immediately following treatment;
#however, the changes were not maintained at the 6-month follow-up.
#Moreover, there were no statistically significant between-group differences at either posttreatment or the 6-month follow-up.
#Inconsistent with findings from previous research examining the efficacy of MST for reducing juvenile delinquency (Henggeler et al., 1997), reductions in criminal activity were not significantly different for youth in the MST condition.
#There was, however, a significant reduction in out-of-home placement for youths in the MST condition, compared with youths in the US condition.
''Calculations of clinical significance'' related to substance use reveal that the changes in substance use were not clinically significant for either MST or the US condition.
Similarly, ''effect sizes'' were small for substance use changes at both posttreatment and the 6-month follow-up assessment .... NB Moreover, there were no betweengroup differences found for substance use. This is particularly
concerning ''because 78% of youths in the US condition received no treatment at all''.
STRENGTH of the study was the high retention of youths in Rx

J. Acad. Child Adolesc. Psychiatry, 2002, 41(7):868–874.
4 stars because long follow up, but rather low power and not very impressive results!
''Objective'':
4-year outcomes (longest yet) of an evidence-based treatment of substance-abusing juvenile offenders.
follow on from [[Henggeler et al 1999]]
This study examined the ''4-year outcomes'' from a ''randomized clinical trial'' of MST with
118 juvenile offenders meeting formal diagnostic criteria for
#substance abuse (56%) or
#dependence (44%)
Although [[Henggeler et al 1999]] demonstrated
#favorable findings regarding treatment completion (98%; Henggeler et al., 1996),
#increased mainstream school attendance (Brown et al., 1999), and
#costsavings (Schoenwald et al., 1996),
outcomes regarding the follwing were not as favorable or long-lasting:
#criminal activity,
#substance use, and
#mental health functioning
(cf those achieved in three earlier randomized trials of MST with chronic and violent juvenile offenders who did not necessarily have substance abuse problems (Borduin et al., 1995; Henggeler et al., 1991, 1992, 1997).
That is, significant treatment effects were not observed in the present study for measures of criminal behavior, biological
indices of drug use, or mental health measures.
Significant treatment effects for substance use were reported at posttreatment but were not maintained at 6-month followup.
Thus the present study provides a long-term follow-up of a randomized trial of an evidence-based treatment that had mixed results for substance-abusing juvenile offenders in the short-term.
''Method:''
Eighty of 118 substance-abusing juvenile offenders participated in a follow-up 4 years after taking part in a randomized clinical trial comparing multisystemic therapy (MST) with usual community services. @@(NB lost 32% of sample in the 4 years - possibly the most disconnected/poorest outcomes??)@@ and the MST group were OLDER than the CS group.
@@Rather low powered study, so Rx effects that were icked up were picked up //in spite// of low power@@
A multimethod (self-report, biological, and archival measures) assessment battery was used to measure the criminal behavior, illicit drug use, and psychiatric symptoms of the participating young adults.
''Results:''
Analyses demonstrated significant long-term treatment effects for:
#aggressive criminal activity (0.15 versus 0.57 convictions per year) but not for property crimes.
#Findings for illicit drug use were mixed, with biological measures indicating significantly higher rates of ''marijuana abstinence'' for MST participants (55% versus 28% of young adults). ''However'', //use// of CBS was reported as higher in the MST than in the Community Servces group(Mean=4.92 SD=2.35 in the MST group, and Mean=5.14 SD=2.43 in the CS group ~ non signif difference... tho' the MST group were OLDER than the CS group)
#Long-term treatment effects were not observed for psychiatric symptoms.
''Conclusions:''
Findings provide some support for the long-term effectiveness of an evidenced-based family-oriented treatment of substance-abusing juvenile offenders. The clinical, research, and policy implications of these findings are noted.

Henggeler SW, Halliday-Boykins CA, Cunningham PB, Randall J, Shapiro SB, Chapman JE (2006)
!Juvenile Drug Court: Enhancing Outcomes by Integrating ~Evidence-Based Treatments.
Journal of Consulting and Clinical Psychology 2006, Vol. 74, No. 1, 42–54
RANDOMISED clinical Trial of 4 different treatment conditions for:
n=161 (screened from 2123 referrasl to Juvenile Justice system, fitting study criteria)
Offending
SUD (diagnosed with DSM IV)
adolescents aged 12 - 17
(Youths averaged 15.2 years of age (SD =1.1); 83% were male, and 17% were female. Racial representation reflected that of
youths in the juvenile justice system in Charleston, South Carolina, with 67% African American, 31% White, and 2% biracial - lower SES, etc, including: Fifty-seven percent of the youths met diagnostic criteria for at least one co-occurring psychiatric disorder. The most prevalent externalizing disorders were conduct disorder (36%), oppositional defiant disorder (24%), and attention-deficit disorder of any type (9%). The most prevalent internalizing disorders were specific phobias (14%), major depression (6%), and obsessive–compulsive disorder (4%).)
''4 x 3 factorial design'':
__''Treatments''__
#Family court (referred to state drug treatment services -> directed to attend group treatment for 1.5 hours, 4 days a week for 12 weeks. The group focused on risk reduction, peer influence, conflict resolution, and anger management. CBT and Systemic basis, not manualised.)
#Drug Court (from weekly to three weekly attendance, urinalsysis with negative consequences for positive screens, positive incentives for negative screens, etc... standard duration 12/12)
#Drug Court + MST
#Drug Court + MST + Contingency Management (a voucher system that rewarded clean substance screens, a detailed functional analysis of druguse behavior that served as the basis for self-management planning, and protocols for self-management.)
(Group diffs - by chance, signif higher alc use in DC/MST/CM group, and this group had signif higher polydrug use than the DC gp too)
then __''time of assessments''__:
#pre treatment (at recruitment)
#4/12 (roughly end of treatment with MST)
#12/12 post recruitment)
Treatment fidelity measures ++
Outcome measures:
Form 90 (TLFB) and others ++
''Follow up'': 83.9% families attended all three assessments
''Dose of treamtent'': only MST arms measured - c 66 - 57 hrs contact... the DC and FC arms unreliable records - assumed LESS than the MST arm.
''__RESULTS__''
''Urinalysis'':
post hoc analyses showed that youths in the DC/MST and DC/MST/CM conditions had significantly lower percentages of positive drug screens than did their DC counterparts ( ps=.001; DC = 45%, DC/MST = 7%, DC/MST/CM = 17%). In comparison with DC youths, counterparts in the DC/MST and DC/MST/CM conditions had very large Effect Sizes at T2 (1.38 and 2.05, respectively), and these remained large at T3 (1.27 and .82, respectively).
''Self Report'':
The Effect Sizes from //self report// (Form ~90/TLFB) parallel these between-groups differences... but... although youths in the DC/MST and DC/MST/CM conditions frequently reported better outcomes than did FC counterparts, ''in no comparison did DC/MST or DC/MST/CM produce outcomes superior to DC for the self-report measures''.
"In consideration of these outcomes and the corresponding ESs, it seems reasonable to contend that DC was more effective than FC at reducing youth substance use, DC/MST was slightly more effective than DC, and DC/MST/CM was slightly more effective than DC/MST. This view is supported, in part, by the findings from the drug urine screens. Here, the MST conditions were shown to be considerably more effective than DC at decreasing cannabis use during both the early and latter stages of drug court. In addition, though not significant, youths in the DC/MST/CM condition averaged fewer positive screens than did their DC/MST counterparts (18% vs. 28%) during the initial 4 months of drug court when these treatments were being delivered."
''Psychiatric comorbidities''
were less successfully adressed by the MST conditions, altho the CM delivered reasonable effect sizes - generally earlier symptom decrease over non MST conditons, but no difference at longer term follow up.
''Offending outcomes''
//Not// significant improvements in rearrest or incarceration in the MST additions to the DC arms, cf. the FC. (A threat if Health and Justice components are not closely integrated - previoulsy MST shown to reduce these) "across published MST outcome studies, the average ESs for reductions in rearrest and incarceration have been greater than .50 (Curtis et al., 2004). Yet, the MST conditions showed no such effects in comparison with FC in the present study."
... possibly because the DC arm involved much more supervision than the FC arm, and this meant that DC youths were more likely to be picked up for misdemeanours, even tho their rate was actually reduced compared to the FC kids, whose offending presumably passed unnoticed?
Limitations:
the present study was part efficacy trial (e.g., therapists employed by the research center, excellent supervision) and part effectiveness trial (e.g., minimal exclusion criteria, implementation in community settings). As such, one cannot assume that the favorable results for DC/MST and DC/MST/CM will easily transport to other community-based settings (Henggeler, 2004).
Most promising effets at 12/12 follow up - await 5 year follow up of this study.

Hides L, Carroll S, Catania L, Cotton SM, Baker A, Scaffidi A, Lubman DI. (2010) Outcomes of an integrated cognitive behaviour therapy (CBT) treatment program for co-occurring depression and substance misuse in young people. Journal of Affective Disorders 121; 169–174.
!Abstract
!!!Background:
There are high rates of co-occurring depression among young people with substance use disorders. While there is preliminary evidence for the effectiveness of integrated cognitive behaviour therapy (CBT) in combination with antidepressants among alcohol and substance dependent adolescents and adults with co-existing depression, no studies have
examined the effectiveness of integrated CBT interventions in the absence of pharmacotherapy.
The aim of the current study was to determine the outcomes of an integrated CBT intervention for co-occurring depression and substance misuse in young people presenting to a mental health setting.
!!!Methods:
Sixty young people (aged 15 to 25), with a DSM-IV diagnosis of Major Depressive
Disorder and concurrent substance misuse (at least weekly use in the past month) or disorder were recruited from a public youth mental health service in Melbourne, Australia.
Participants received 10 sessions of individual integrated CBT treatment delivered with case management over a 20-week period.
!!!Results:
The intervention was associated with significant improvements in depression, anxiety,
substance use, coping skills, depressive and substance use cognitions and functioning at mid- (10 weeks) and post- (20 weeks) treatment.
These changes were maintained at 6 months follow-up (44 weeks).
!!!Conclusions:
These results provide preliminary evidence for the effectiveness of the integrated
CBT intervention in young people with co-occurring depression and substance misuse. Further studies using randomised controlled designs are required to determine its efficacy.
!DB comments
No control group - just an outcomes study, age range is up to 25.
encouraging, but doesn't add anything concrete to the evidence base as yet - for inclusion in chapter as it justifies future trials of integrated CBT/MET in co-morbidly depressed SUD youth.

In line with the standard procedure for conducting such reviews, a hierarchy of evidence has been developed to distinguish studies according to their susceptibility to bias (Sheldon, Song, & ~Davey-Smith, 1993). Evidently, randomised controlled trials with manualised treatments and homogenous samples are more reliable than trials where randomisation was not possible and the treatment cannot be described. The hierarchy of evidence is in line with generally accepted criteria described in the Cochrane Reviewers' Handbook (Clarke & Oxman, 1999), and other publications (e.g. Rosenthal, 1995; Woolf et al., 1990). The broad categories are as follows:
''(i)'' - - - [[(i) randomised controlled trials]],
''(ib)''- - - [[(ib) systematic reviews and meta-analyses]],
''(ii)''- - - [[(ii) other trials]]: a controlled trial without randomisation, a quasi experiments, or a failed randomisation]]
''(iib)''- - - [[(iib) experimental single case designs]]
''(iii)''- - - [[(iii) cohort studies]], preferably from more than one centre (a cohort allocates by exposure to treatments and looks for differences in outcomes);
''(iv)''- - - [[(iv) case-control (retrospective) studies]], preferably from several centres (allocates by outcome and looks for differences of exposure – in terms of treatment);
''(v)''- - - [[(v) large differences reported in comparisons]] between times and/or places, with or without interventions;
''(vi)''- - - [[(vi) opinions of respected authorities]] based on clinical experience, descriptive studies, uncontrolled studies and reports of expert committees.
As this review will highlight, for the treatment of some conditions there is an absence of good quality outcome research, and so clinical opinion is the only information available. We rated each citation in the treatment section of each chapter in terms of the broad categories of evidence (i)-(vi).

HOGUE A, LIDDLE HA, DAUBER S, SAMUOLIS J (2004)
!LINKING SESSION FOCUS TO TREATMENT OUTCOME IN ~EVIDENCE-BASED TREATMENTS FOR ADOLESCENT SUBSTANCE ABUSE
Psychotherapy: Theory, Research, Practice, Training 2004, Vol. 41, No. 2, 83–96
!Gets 5Stars because of the interesting questions it poses -
whether the effectiveness of specific therapies is due to specific techniques/foci of attention, etc, -
Drawbacks... ''small sample size'', not an RCT as such (part of larger RCT)...
''NO RANDOMISATION OF THE EXTENT OF FAMILY OR INDIVIDUAL FOCUS....''
!abstract:
The relation between ''specific therapy techniques'' and ''treatment outcome'' was examined for 2 empirically supported
treatments for adolescent substance abuse: individual cognitive–behavioral therapy and multidimensional family therapy.
''__Individual-focussed Vs Family-focussed__''
Participants were 51 inner-city, substance-abusing adolescents receiving outpatient psychotherapy ''within a larger randomized trial''. (67% male youths) The ethnic composition was 65% African American, 25% European American, and 10% Hispanic American. Adolescent characteristics included the following: mean age was 15.2 years (SD=1.3); 84% of the adolescents were enrolled in school at intake, 63% were on juvenile probation, 22% were court ordered into treatment, and 16% attended previous drug
counseling; 61% were living in single-parent households, 10% were living with both biological parents, and 29% had various other family compositions; and 37% had a yearly household income less than $10,000.
One session per case was evaluated using a 17-item observational measure of model-specific techniques and therapeutic foci.
"Therapy techniques were
measured using observational scales from a psychotherapy
process instrument developed in a
previous study on this sample (Hogue et al.,
1998). The current study extended the Hogue et
al. 1998 study by adding new items to the observational
scales, conducting new exploratory factor
analyses of the expanded scale, increasing the
number of participants, and conducting process–
outcome analyses."
Exploratory factor analysis identified 2 subscales, Adolescent Focus and Family Focus, with strong interrater-reliability and internal consistency.
Outcomes measures: TLFB and CBCL
Process–outcome analyses revealed that ''family focus'', but ''not adolescent focus'', predicted posttreatment improvement in drug use, externalizing symptoms, and internalizing symptoms within both study conditions.
(In fact just as effective to apply family focus in individual CBT sessions as in Family-based MDFT)
''"More important, the findings
suggest a tangible option for real-world
therapists who prefer working alone with adolescents
and face insurmountable barriers to including
family members in treatment for adolescent
drug problems: incorporate work on family
themes into treatment plans."''

Hogue A, Dauber S, Samuolis J, Liddle HA (2006)
!Treatment Techniques and Outcomes in Multidimensional Family Therapy for Adolescent Behavior Problems
Journal of Family Psychology, 2006, Vol. 20, No. 4, 535–543
!!!Context
Sub-part of the CYT study - expanding on earliuer smaller study [[Hogue et al 2004]]
ProcessResearch - what are the specific techniques that are associated with outcomes?
!Sample
The sample for this study was composed of 63 substanceabusing
adolescents receiving MDFT during a randomized clinical
trial (n = 224) (CYT).
Eligible adolescents were between the ages of 13
and 17, were currently using illicit drugs, and had a caregiver able
to participate in assessment and treatment sessions. Exclusion
criteria included a history of mental disability or organic disorder,
the need for inpatient detoxification, and suicidal ideation.
The 63 cases selected for inclusion in the current study were those MDFT
cases that had completed a pretreatment assessment, at least one
follow-up assessment (6- or 12-month), and at least one videotaped
therapy session. Selected cases attended an average of 13.8 sessions
(SD = 8.4); 37% of the sample dropped out of treatment
before having completed 10 sessions.
generally ethnically mixed and low SES: 83% male, with an average age of
15.1 years (SD = 1.3). The ethnic composition was 71% African
American, 19% European American, and 10% Hispanic American.
Fifty-three percent of the adolescents were living in single-parent
households, 25% were living with both biological parents, and
22% had various other family compositions
Outcome measures ++
Video ratings of sessions
Therapist Behaviour Rating Scale (TBRS) = a validated adherence porocess recording system
Looked at TWO FACTORS:
#FAMILY FOCUS
#ADOLESCENT FOCUS
results:
#Greater use of ''family focussed techniques predicted reduced externalizing'' //when Adolescent Focus was also high// (B=–10.74, p<.01, d=0.76) but not when Adolescent Focus was low (B =1.16, p<.75).)
#Increased family focus predicted increased Family coheseion at 12/12, ditto with adolescent techniques
#Justification for continued development of multi-domain simultaneous interventions but...
#...''Neither adolescent nor family techniques as measured in this study predicted reductions in drug use''.
Main outcomes from the randomized trial show that MDFT significantly reduced substance use up to 1 year following treatment. This is hard evidence that the MDFT therapist interventions measured by the TBRS instrument did not fully capture all curative aspects of the treatment model.
!DB Wrote:
In the second study (part of the CYT) a slightly larger sample (n = 63, being those MDFT cases for whom there was a completed 12 month outcome assessment, as well as at least one videotaped session for analysis) was examined. The results were not quite so clear cut, however: increased Family Focus did predict reduced externalizing symptoms, but this effect was present only when Adolescent Focus was also high (B = –10.74, p < 0.01, d = 0.76) but not when Adolescent Focus was low (B = 1.16, p < 0.75). However, neither adolescent nor family techniques as measured in this study predicted reductions in drug use at 12 months, even though such reductions were found in the MDFT-treated group within the larger study. The authors’ conclusion was that whatever the true “curative aspects” of MDFT are, the measures of ‘Family focus’ and ‘Adolescent focus’ by the Therapist Behaviour Rating Scale were not adequately capturing them.

''Adolescent heroin use: a review of the descriptive and treatment literature
Christian J. Hopfer, M.D.a,*, Elizabeth Khuri, M.D.b, Thomas J. Crowley, M.D.a,
Sabrina Hooks, B.A''
Journal of Substance Abuse Treatment 23 (2002) 231– 237
''Abstract''
The prevalence of heroin use is rising among young people. We reviewed descriptive and treatment studies of heroin-using youth. Medline and Psychinfo were searched with the following kewords: heroin or opiate; and adolescent or young or juvenile.
''Nine articles describing treatment'' and ''five articles describing clinical characteristics'' of youth with heroin use were reviewed.
Descriptive studies of heroin-using youth demonstrate ''substantial polysubstance use'' and ''psychiatric comorbidity''.
The largest treatment study found that, of four different treatment modalities, ''methadone maintenance had the highest retention rate''. (@@Crome, I. B., Christian, J., & Green, C. (1998). Tip of the national iceberg? Profile of adolescent patients prescribed methadone in an innovative community drug service. Drug, Education, Prevention, and Policy, 5,
195– 197@@.)
''For youth who stayed in treatment for at least 6 months, therapeutic communities or drug-free treatment resulted in better outcomes compared with methadone maintenance.''
@@No controlled treatment trials were found@@.
@@''Length of time in treatment, regardless of modality, was the best predictor of outcome.''@@
The rise of heroin use among adolescents and young adults calls for descriptive studies as well as controlled treatment studies.

Horvath AO, Symonds BD. Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology 1991;
38(2):139–149
relationship between ''outcomes'' and the ''quality of early therapeutic alliance'' - especially as it is judged by the patients
Not reviewed so only 1Star
See also [[Shirk and Carver 2003]]

There are a lot of interesting people using ~TiddlySpace that you might like to keep track of and interact with. There are a number of ways of doing this.
If you see a number in the speech bubble in one of your tiddlers, it means that someone is writing about the same thing as you. You can find out what they're saying by clicking on it. Likewise, if you see something interesting in someone else's space, you can respond to it and write up your own thoughts on the subject by clicking "Reply to this tiddler".
Additionally, if you find anyone interesting, or you find an interesting looking space and you'd like to know when it's changed, you can "follow" that space. To do this, simply create a tiddler with the title: {{{@space-name}}} and tag it {{{follow}}}. If you want, you can store some notes about that space in the body of the tiddler.
If you then want to know what happening, simply [[include|How do I include/exclude spaces?]]@docs the @tivity space and then visit your activity stream at [[/activity|/activity]], or just visit the @tapas space directly.
!Not sure who to follow?
Here's a few suggestions:
* @fnd
* @cdent
* @pmario
* @bengillies
* @dickon

An Evaluation of Drug Treatments for Adolescents in 4 US Cities
Yih-Ing Hser, PhD; Christine E. Grella, PhD; Robert L. Hubbard, PhD; Shih-Chao Hsieh, MS;
Bennett W. Fletcher, PhD; Barry S. Brown, PhD; M. Douglas Anglin, PhD
ARCH GEN PSYCHIATRY/VOL 58, JULY 2001
studied 1167 @@(= 67% of the 1732 patients consecutively admitted, who completed interviews at 1 year post-treatment - HIGH ATTRITION RATE - addressed see below)@@ adolescents (age range, 11- 18 years; 368 females, 799 males)from 4 US cities (Pittsburgh, Pa; Minneapolis, Minn; Chicago, Ill; and Portland, Ore)
using a naturalistic, nonexperimental evaluation design.
These adolescents were consecutive admissions during the period from 1993 to 1995 at 23 community-based treatment programs in the Drug Abuse Treatment Outcome Studies for Adolescents. Included were:
#418 admissions to 8 residential programs (mixed prgrammes of indiv, family, group input)
#292 admissions to 9 outpatient drug-free programs (nearly all (but one) emphasis on Family theroay, but daily groups, individual, etc)
#457 admissions to 6 short-term inpatient programs (intensive counselling or 12-step, plus Family work in medically controlled environment - disch to outpaitient Rx)
The recent @@Drug Abuse Treatment Outcome Studies for Adolescents (DATOS-A)@@ is the first large-scale effort designed specifically toevaluate treatment outcomes among adolescents. Treatment programs included in DATOS-A were community programs specifically intended to treat adolescents with drug problems. This article reports results of an assessment of treatment outcomes among adolescent patients participating in DATOS-A.
The study addressed 3 key research questions:
(1) What were the patterns of drug use and other problem behaviors of these adolescents before they entered the DATOS-A treatment programs?
(2) Were there changes in their drug use and other problem behaviors after treatment?
(3) Was the length of stay in treatment related to their posttreatment outcomes?
''Sample:''
31.5% female, 66.2% white, 18.3% black, 9.3% Hispanic, and 6.3% other ethnic groups.
The mean±SD age was 15.7±1.3 years.
More than 80% were currently in or had completed the ninth grade.
One third (37.4%) were not attending school at the time of treatment admission.
Almost half (47.1%) of these adolescents reported marijuanause
as their primary drug problem.Anadditional 20.6%
cited alcohol use as their primary problem.
''Attrition:''
''Group retained for analysis at 1 year:'' "We compared the subjects without follow-up interviews with those who completed follow-up interviews and ''did not find any differences in'':
#age,
#use of drugs (eg, marijuana, alcohol, cocaine, or other illicit drugs), or
#enrollment in school.
#treatment retention in STI or ODF programs,
@@''but''@@
#patients in RES programs who completed follow-up stayed in treatment significantly longer than those without follow-up (mean days in treatment, 124.4 vs 105.4, respectively)
#The follow-up sample had a higher proportion of female (31.5%) and white (66.2%) participants and lower proportions of black (18.3%) and Hispanic (9.3%) participants compared with those without follow-up (21.3% female, 60.3% white, 21.9% black, and 12.5% Hispanic)"
Measures
random urinalysis in 25% of sample (85% of them consented)
''Problem severity index'' (presence of no of the following:
#multiple drug use (use of >3 drugs during the year before treatment),
#dependence on alcohol or any drug (by DSM-III-R criteria16),
#mental disorder (conduct disorder, attention-deficit/hyperactivity disorder, panic disorder, anxiety disorder, or major depressive disorder, using DSM-III-R criteria),
#criminal involvement,
#unstable living arrangement,
#family alcohol and other drug (AOD) problems,
#deviant reference group,
#academic failure prior to DATOS-A treatment
''Outcome measures''
Outcome measures included drug-use patterns, psychological adjustment, criminal involvement, and school performance
''Results''
Overall, during the year after treatment, compared with the year before treatment, there were significant improvements in:
#drug use,
#psychological adjustment,
#school performance, and
#criminal activity
Weekly or more frequent CBS use dropped from 80.4% in the year before admission to 43.8% in the year following treatment.
Similarly, heavy drinking dropped from 33.8% to 20.3%,
use of other illicit drugs dropped from 48.0% to 42.2%,
criminal activities dropped from 75.6% to 52.8%.
Additionally, patients reported better psychological adjustment in terms of reduced suicidal thoughts and hostility, and increased self-esteem.
During the year after treatment, more patients attended school and reported average or better than average grades compared
with the year before treatment.
NOT IMPROVED:
cocaine use increased to 19.2% at follow-up from 16.5% before intake (Qw1=3.76; P=.05), mainly due to increases among patients in STI (Qw1=9.52; P=.002) and ODF (Qw1=6.95; P=.008) programs.
Patients in ODF programs also showed no improvement in their use of hallucinogens and stimulants, and they significantly
increased use of illicit drugs other than marijuana (Qw1=4.94, P=.03).
Additionally, although the level of illegal acts was reduced from pretreatment levels for adolescents treated in ODF programs (Qw1=18.04, P,.001), there was a (nonsignificant) increase in arrest rates for these patients.
''LOGISTIC REGRESSIONS TO LOOK AT Rx RETENTION''
Even including STI programs, longer time in treatment was found to be significantly related to
#lower drug use (eg, any marijuana use, or any drug or alcohol use) and
#lower rates of arrest following treatment.
This important finding does not establish thresholds for necessary minimum treatment durations, but it does replicate a finding that has been repeatedly demonstrated in adult evaluation research.
''FUTURE NEEDS:''
#Improve retention
#Address complex multiople comorbidiites
''LIMITATIONS''
#NO Conrol condition
#33% loss of sample at 1 year of posttreatment follow-up;
#the fact that study results are mostly based on self-report; and
#the fact that treatment effects may be somewhat inflated, particularly for patients in RES programs because those patients lost to follow- up seemed to have shorter lengths of stay in treatment than those who completed follow-up interviews

Nicotine Patch Therapy in 101 Adolescent Smokers Efficacy, Withdrawal Symptom Relief, and Carbon Monoxide and Plasma Cotinine Levels
Richard D. Hurt, MD; Gary A. Croghan, PhD, MD; Scott D. Beede, MD;
Troy D. Wolter, MS; Ivana T. Croghan, PhD; Christi A. Patten, PhD
Arch Pediatr Adolesc Med. 2000;154:31-37
!Abstract:
Objectives:
To determine the efficacy of nicotine patch therapy in adolescents who want to stop smoking and to assess biochemical markers of smoking and nicotine
intake.
Design:
Nonrandomized, open-label trial using a 15mg/16 h patch.
Setting:
Two midwestern cities.
Subjects:
One hundred one adolescents aged 13 through 17 years smoking at least 10 cigarettes per day (cpd).
Intervention:
Six weeks of nicotine patch therapy and follow-up visits at 12 weeks and 6 months.
Main Outcome Measures:
Self-reported smoking abstinence verified by expired-air carbon monoxide (CO) level of no more than 8 ppm, nicotine withdrawal symptoms, and plasma cotinine level.
!Results:
Forty-one participants were female (mean [± SD] age, 16.5 [± 1.1] years).
Median baseline smoking rate was 20.0 cpd (range, 10-40 cpd).
Biochemically confirmed point prevalence smoking abstinence was 10.9% (11/101) at 6 weeks and 5.0% (5/101) at 6 months.
The mean (± SD) plasma cotinine level at baseline was 1510.9 ± 732.7 nmol/L; for nonsmoking subjects at weeks 3 and 6, 607.8 ± 386.2 and 710.0 ± 772.5 nmol/L, respectively. Plasma cotinine levels were correlated with CO levels at baseline (r = 0.27; P = .006), week 3 (r = 0.34; P = .004), and week 6 (r = 0.26; P = .03) and with mean cigarettes smoked per day during weeks 3 (r = 0.24; P = .04) and 6 (r = 0.30; P = .02). Mean smoking rates decreased significantly during the study, an effect that lessened at 12 weeks and 6 months.
!Conclusions:
Nicotine patch therapy plus minimal behavioral intervention does not appear to be effective for treatment of adolescent smokers. Plasma cotinine and CO levels appear to be valid measures of smoking rates during the cessation process, but not at baseline. Smoking rates were reduced throughout the study. Additional pharmacological and behavioral treatments should be considered in adolescent smokers.
!@@DB notes@@
self -selected group from fliers etc, smokers of >10 per day for last year. Standard exclusions
Intent to Treat analysis, but no control group.
Biochemical markers (CO and Cotinine)
Intervention was @@mimimal@@:
"Adolescents were given a daily diary to record the number
of cigarettes smoked and the nicotine withdrawal symptoms
experienced between the informational meeting and
their first clinic visit before their target quit date. Nicotine
withdrawal symptoms included desire to smoke; anger, irritability,
or frustration; anxiety or nervousness; difficulty
concentrating; impatience or restlessness; hunger; awakening
at night; and depression.20 Each symptom was scored as
none (0), slight (1), mild (2), moderate (3), or severe (4).
At the first clinic visit, a physician collected medical history
information (including the adolescent’s self-report of medical
and psychiatric problems), performed a brief physical examination,
and delivered a strong, personalized message about
smoking cessation to each subject according to the guidelines
of the National Cancer Institute.21 Subjects were instructed
in the use of the nicotine patch (Nicotrol; 15 mg/16
h) and were given self-help material from the package insert
used in the over-the-counter product. Brief individual
counseling (10-15 minutes) was provided by a trained study
assistant at the subject’s request. No additional materials or
behavioral instructions were provided."
comments by [[Hanson et al 2003]] - "For instance, in a nonrandomized,
open-label trial of the nicotine patch among adolescents
(Hurt et al., 2000), the mean reduction in
number of cigarettes smoked per day among continuing
smokers was 84.1% at the end of treatment (from
18.2 cigarettes per day to 2.9 cigarettes per day)." - but this was not obviously related to the PATCH!

!A forthcoming study of MDFT
Author: H. Rigter, I. Pelc, P. Tossmann, O. Phan, E. Grichting, V. Hendriks and C. Rowe
Year: 2010
Title: INCANT: A transnational randomized trial of Multidimensional Family Therapy versus treatment as usual for adolescents with cannabis use disorder
Journal: BMC Psychiatry
Volume: 10
Issue: 28
Abstract: Background: In 2003, the governments of Belgium, France, Germany, the Netherlands and Switzerland agreed that there was a need in Europe for a treatment programme for adolescents with cannabis use disorders and other behavioural problems. Based on an exhaustive literature review of evidence-based treatments and an international experts meeting, Multidimensional Family Therapy (MDFT) was selected for a pilot study first, which was successful, and then for a joint, transnational randomized controlled trial named INCANT (INternational CAnnabis Need for Treatment).Methods/design: INCANT is a randomized controlled trial (RCT) with an open-label, parallel group design. This study compares MDFT with treatment as usual (TAU) at and across sites in Brussels, Berlin, Paris, The Hague and Geneva. Assessments are at baseline and at 3, 6, 9 and 12 months after randomization. A minimum of 450 cases in total is required; sites will recruit 60 cases each in Belgium and Switzerland, and a maximum of 120 each in France, Germany and the Netherlands.Eligible for INCANT are adolescents from 13 through 18 years of age with a cannabis use disorder (dependence or abuse), with at least one parent willing to take part in the treatment. Randomization is concealed to, and therefore beyond control by, the researcher/site requesting it. Randomization is stratified as to gender, age and level of cannabis consumption.Assessments focus on substance use; mental function; behavioural problems; and functioning regarding family, school, peers and leisure time.For outcome analyses, the study will use state of the art latent growth curve modelling techniques, including all randomized participants according to the intention-to-treat principle.INCANT has been approved by the appropriate ethical boards in Belgium, France, Germany, the Netherlands, Switzerland, and the University of Miami Miller School of Medicine. INCANT is funded by the (federal) Ministries of Health of Belgium, Germany, the Netherlands, Switzerland, and by MILDT: the Mission Interministerielle de Lutte Contra la Drogue et de Toximanie, France.Discussion: Until recently, cannabis use disorders in adolescents were not viewed in Europe as requiring treatment, and the co-occurrence of such disorders with other mental and behavioural problems was underestimated. This has changed now.Initially, there was doubt that a RCT would be feasible in treatment sectors and countries with no experience in this type of study. INCANT has proven that such doubts are unjustified. Governments and treatment sites from the five participating countries agreed on a sound study protocol, and the INCANT trial is now underway as planned

Interventions using technology or otherwise seen as "innovative" so that they don't easily fit into another existing category!

BySubstance

Author: C. D. Jensen, C. C. Cushing, B. S. Aylward, J. T. Craig, D. M. Sorell and R. G. Steele
Year: 2011
Title: Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review
Journal: Journal of Consulting and Clinical Psychology
Volume: 79
Issue: 4
Pages: 433-440
Date: Aug
Abstract:
!Objective:
This study was designed to quantitatively evaluate the effectiveness of motivational interviewing (MI) interventions for adolescent substance use behavior change.
!Method:
Literature searches of electronic databases were undertaken in addition to manual reference searches of identified review articles. Databases searched include PsycINFO, PUBMED/MEDLINE, and Educational Resources Information Center. Twenty-one independent studies, representing 5,471 participants, were located and analyzed.
!Results:
An omnibus weighted mean effect size for all identified MI interventions revealed a small, but significant, posttreatment effect size (mean d = .173, 95% CI [.094, .252], n = 21). Small, but significant, effect sizes were observed at follow-up suggesting that MI interventions for adolescent substance use retain their effect over time. MI interventions were effective across a variety of substance use behaviors, varying session lengths, and different settings, and for interventions that used clinicians with different levels of education.
!Conclusions:
The effectiveness of MI interventions for adolescent substance use behavior change is supported by this meta-analytic review. In consideration of these results, as well as the larger literature, MI should be considered as a treatment for adolescent substance use

Jensen CD, Cushing CC, Aylward BS, Craig JT, Sorell DM, and Steele RG (2011) ''Effectiveness of Motivational Interviewing Interventions for Adolescent Substance Use Behavior Change: A Meta-Analytic Review.'' Journal of Consulting and Clinical Psychology 2011, Vol. 79, No. 4, 433–440
!Abstract
!!!Objective:
This study was designed to quantitatively evaluate the effectiveness of motivational interviewing (MI) interventions for adolescent substance use behavior change.
!!!Method:
Literature searches of electronic databases were undertaken in addition to manual reference searches of identified review articles. Databases searched include PsycINFO, PUBMED/MEDLINE, and Educational Resources Information Center.
Twenty-one independent studies, representing 5,471 participants, were located and
analyzed.
!!!Results:
An omnibus weighted mean effect size for all identified MI interventions revealed a
small, but significant, posttreatment effect size (mean d = .173, 95% CI [.094, .252], n = 21).
Small, but significant, effect sizes were observed at follow-up suggesting that MI interventions for adolescent substance use retain their effect over time.
MI interventions were effective across a variety of substance use behaviors, varying session lengths, and different settings, and for interventions that used clinicians
with different levels of education.
!!!Conclusions:
The effectiveness of MI interventions for adolescent substance use behavior change is supported by this meta-analytic review. In consideration of these results, as well as the larger literature, MI should be considered as a treatment for adolescent substance
use.

Abstract:
Treatment of antisocial behavior in children: Current status and future directions.
Source
Psychological Bulletin, Sep 1987, vol. 102, no. 2, p. 187-203, ISSN: 0033-2909.
Publisher: American Psychological Association, US.
Author(s)
Kazdin-Alan-E.
Abstract
Antisocial behavior in children represents a serious and pervasive clinical problem. To date, progress in identifying effective treatments has been relatively slow. The purpose of the present article is to characterize the current status of treatment for antisocial child behavior, to identify promising approaches based on contemporary outcome research, and to note limitations and emergent methodological issues. A central purpose is to identify alternative models of treatment application and evaluation, including the high-strength intervention, amenability-to-treatment, broad-based treatment, and @@chronic-disease models@@. These models are designed to integrate findings regarding characteristics and prognosis of antisocial behavior with outcome research and to accelerate the identification and development of effective treatments. (PsycINFO Database Record (c) 2007 APA, all rights reserved).

A common recommendation for youth treated for substance abuse is to attend
12-step groups. However, little is known regarding the effects of this adult-derived
prescription on substance use outcomes for teens.
This study examined
(a) the relation between 12-step attendance and substance use outcome in the 6 months postdischarge from inpatient care and
(b) a process model of how 12-step attendance during the first 3 months postdischarge affects proximal outcomes of motivation, coping, and self-efficacy, measured at 3 months, and how these, in tum, affect ultimate substance use outcome in the following 3 months.
Adolescent inpatients (N = 99 drawn from 227 consecutive admissions to private in-pt Rx units in California) were assessed during treatment (av length of stay only 12.5 days- S.D. = 9.05!) and 3 and 6 months postdischarge.
PRospective study. No control Group.
Results revealed modest beneficial effects of 12-step attendance, which were mediated by motivation but not by coping or self-efficacy.
Findings suggest that closer attention be paid to motivational factors in the treatment of adolescent substance abuse. A
simultaneous multiple regression revealed
that, after partialing out the effects of aftercare
attendance and number of days abstinent
at baseline, 12-step meeting attendance in the
first 3 months still contributed uniquely to
both substance use outcome variance in the
first 3 months (Beta = .28, p = .007) and the
second 3 months postdischarge (Beta = .23, p =
.03).
Notes:
According to a national study
by Roman and Blum (1998) on a representative
sample of 450 private substance abuse treatment
centers, 90% of the facilities based their treatment
on the 12-step principles of Alcoholics
Anonymous and variations of this model, with
nearly one half of the remaining 10% incorporating
12-step model principles in combination
with other approaches, including encouraged
attendance at 12-step meetings.
Problems with 12 step approaches:
#Adoelscents generally less physical dependence than adults
#Emphasis on the primary causative role of the substance(s) of abuse in the clinical presentation when, more typically, the substance abuse constitutes only one part of a more complicated problem behavior pattern.
#Adolescents mostly in Rx because MANDATED (formally or informally) rather than out of choice.
#Adoelscents reliant on parents for money for tranport etc re. attending 12 step groups afterwards, etc
#Kelly and Myers (1997) revealed that teens who did attend groups consisting of at least a substantial proportion of teenagers had significantly better substance use outcomes at 3 months posttreatment than those who attended predominantly adult meetings.
MOTIVATION
Seems to indicate that 12 step functions by maintaining and enhancing MOTIVATION as the proimary mechanism of action. Maybe that adults with more physical dependency symps need more SKILLS training than adoelscents... "Adolescents
with briefer substance involvement histories may be better able to "self-regulate" their behavior once they reach a commitment to do so."
SELF EFFICACY
Attendance at 12-step meetings did not affect
self-efficacy measured at 3 months. However,
self-efficacy did retain unique explanatory
power in the equation predicting substance use
between 3 and 6 months postdischarge. It may
be that testimonials and admonitions from individuals
who have relapsed, often heard at 12-
step meetings, initially do not enhance confidence.
Instead, such dialogue may again serve
to increase motivation for continued abstinence
and continued attendance.

Kessler RC, Walters EE (198)
!Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey.
Depress Anxiety. 1998;7(1):3-14.
!Abstract
Data on the prevalences, comorbidities, and cohort effects of DSM-III-R major depression (MD) and minor depression (mD) are reported for the nationally representative sample of n = 1,769 adolescents and young adults who participated in the National Comorbidity Survey. Lifetime prevalences are 15.3% (MD) and 9.9% (mD), while 30-day prevalences are 5.8% (MD) and 2.1% (mD). Most cases reported recurrent episodes (73.9% of those with MD and 69.2% with mD) and significant role impairment, including attempted suicide among 21.9% of those with MD. The majority of lifetime cases (76.7% of those with MD and 69.3% with mD) reported other comorbid lifetime NCS/ DSM-III-R disorders. Depression was temporally secondary in the majority of these cases. Number of prior disorders was more important than type of disorders in predicting subsequent depression, raising the possibility that secondary depression is a nonspecific severity marker for earlier disorders. A cohort effect for both MD and mD was documented that persisted even for episodes lasting a year or longer. Increasing prevalences of prior comorbid disorders were found to play an important part in explaining the cohort effect for depression.

Randomized Clinical Trial of the Efficacy of Bupropion Combined With
Nicotine Patch in the Treatment of Adolescent Smokers
Joel D. Killen, Thomas N. Robinson, Seth Ammerman, Chris Hayward, Jayna Rogers, Christi Stone,
Deanne Samuels, Sara K. Levin, Sarah Green, and Alan F. Schatzberg
Journal of Consulting and Clinical Psychology, 2004, Vol. 72, No. 4, 729–735
Abstract with annotations:
@@distinguishing features of the trial (according to authors):@@
#it is perhaps the first randomized controlled trial of pharmacotherapy for adolescent smoking cessation and one of a very few randomized smoking cessation trials for adolescents yet conducted.
#it is to our knowledge the first study with adolescent smokers to examine the efficacy of a treatment combining nicotine replacement therapy with antidepressant medication.
#it is one of the first smoking cessation trials with adolescents to combine relapse prevention skills training with
pharmacotherapy.
543 screened (recruited over 2.5 yrs from 9 schools in the San Francisco Bay area - not clear how they were found...)
-> 226 eligible -> 211 randomised...
Adolescent smokers (N = 211) were randomized to 1 of 2 groups (no stat diffs between groups pre Rx):
(a) nicotine patch plus bupropion SR (sustained release; 150 mg per @@NB the adult dose is 300mg daily - ??possibly why less effective here??@@ ...or
(b) nicotine patch plus placebo.
@@All got Group therapy input@@:
"Participants met weekly in groups (average group size = 8) supervised by trained counselors.
In each 45 min session, counselors:
(a) demonstrated the use of specific, concrete self-regulatory skills for coping with risky situations without resorting to smoking,
(b) provided participants with an opportunity to rehearse modeled skills, and
(c) helped participants develop action plans designed to promote nonsmoking in self-identified, high-risk situations."
@@NB. $50 for completing week 1 assessment, another $50 for completing trial@@
Group skills training sessions were conducted each week by research staff.
Abstinence rates at Weeks 10 and 26 were as follows:
(a) patch plus bupropion, 23% and 8%,
(b) patch plus placebo, 28% and 7%.
@@Lack of a stat signif treatment effect@@
At week 10, the % abstinent: (N Patch + Placebo) = 28% (N Patch + Bupropion) = 23%
At week 26, the % abstinent: (N Patch + Placebo) = 7% (21% self report - missing cotinine tests),(NPatch + Bupropion) = 8% (16% self report - missing cotinine tests)
...but despite this ..."a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time."
Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.
!Funding
This research was funded by National Cancer Institute Grant CA80268.
@@GlaxoSmithKline provided medication and matching placebo@@.

Author: Y. Kim, S. K. Myung, Y. J. Jeon, E. H. Lee, C. H. Park, H. G. Seo and B. Y. Huh
Year: 2011
Title: Effectiveness of pharmacologic therapy for smoking cessation in adolescent smokers: Meta-analysis of randomized controlled trials
Journal: American Journal of Health System Pharmacy
Volume: 68
Issue: 3
Pages: 219-226
Abstract: Purpose. The effectiveness of pharmacologic therapy for smoking cessation in adolescent smokers was evaluated. Methods. In this meta-analysis, the medical literature was searched for randomized controlled trials (RCTs) investigating the effect of pharmacologic therapy for smoking cessation in smokers age 20 years or younger. The overall effect of pharmacologic therapy was based on the longest follow-up data available in each study. The effects of pharmacologic therapy by follow-up period, type of pharmacologic therapy, and type of strategy analysis were also compared among RCTs. Secondary outcome measures were adverse events reported from each study. Results. Six RCTs involving 816 smokers age 12-20 years were included in the final analysis. No significant increase in abstinence rates was detected with pharmacologic therapy (relative risk [RR], 1.38; 95% confidence interval [CI], 0.92-2.07; I<sup>2</sup> = 0.0%) in a fixed-effects meta-analysis. Simi larly, no significant increase in abstinence rates was found in subgroup meta-analyses of studies with both short-term (<=12 weeks) (RR, 1.23; 95% CI, 0.92-1.65) and mid-term (26 weeks) follow-up periods (RR, 1.60; 95% CI, 0.90-2.82). Although few serious adverse events were reported, there was no evidence directly linking these effects to the pharmacologic therapy used. Conclusion. A meta-analysis found that pharmacologic therapy for smoking cessation among adolescent smokers did not have a significant effect on abstinence rates at short-term and mid-term followup times of <26 weeks, and the RCTs examined found few adverse events. However, the results may have been affected by the limited number of participants in published trials.

!Author:
I. M. Koning, R. J. Van Den Eijnden, J. E. Verdurmen, R. C. Engels and W. A. Vollebergh
!Year:
2011
!Title:
Long-term effects of a parent and student intervention on alcohol use in adolescents: A cluster randomized controlled trial
!Journal:
American Journal of Preventive Medicine, Volume: 40,Issue: 5,Pages: 541-547
!Abstract:
''Background'':
Early onset of drinking among Dutch adolescents is highly prevalent. A lower age of onset is associated with several developmental and social risks.
''Purpose:'' To evaluate the long-term effectiveness of two preventive interventions targeting heavy drinking in third-year high school students.
''Design:'' Cluster RCT using four conditions for comparing two active interventions (separately and simultaneously) with a control group.
''Setting/participants:'' 152 classes of 19 high schools in the Netherlands; 3490 first-year high school students (M=12.6 years, SD=0.49) and their parents.
!!Intervention:
(1) parent intervention aimed at encouraging restrictive parental rule-setting concerning their children's alcohol consumption;
(2) student intervention aimed at increasing self-control and healthy attitudes toward alcohol, consisting of four digital lessons based on the principles of the theory of planned behavior and social cognitive theory;
(3) interventions 1 and 2 combined; and
(4) the regular curriculum as control condition.
!!Main outcome measures:
Incidence of (heavy) weekly alcohol use at 34 months (2009) after baseline measurement (2006).
!!Results:
There were 2937 students eligible for analyses in this study. At follow-up, only the combined studentparent intervention showed substantial and significant effects on heavy weekly and weekly drinking.
!!Conclusions:
@@The short-term effects found in the present study further support that adolescents as well as their parents should be targeted in order to delay the onset of (heavy) drinking@@

Koning IM, van den Eijnden RJ, Verdurmen JE, Engels RC, Vollebergh WA. (2011) ''Long-Term Effects of a Parent and Student Intervention on Alcohol Use in Adolescents:
A Cluster Randomized Controlled Trial.'' Am J Prev Med 2011;40(5):541–547
!Abstract
!!!Background:
Early onset of drinking among Dutch adolescents is highly prevalent.
A lower age of onset is associated with several developmental and social risks.
!!!Purpose:
To evaluate the long-term effectiveness of two preventive interventions targeting heavy
drinking in third-year high school students.
!!!Design:
Cluster RCT using four conditions for comparing two active interventions (separately and
simultaneously) with a control group.
!!!Setting/participants:
152 classes of 19 high schools in the Netherlands;
3490 fırst-year high school students (M=12.6 years, SD=0.49) and their parents.
!!!Intervention:
(1) parent intervention aimed at encouraging restrictive parental rule-setting concerning
their children’s alcohol consumption;
(2) student intervention aimed at increasing selfcontrol
and healthy attitudes toward alcohol, consisting of four digital lessons based on the principles of the theory of planned behavior and social cognitive theory;
(3) interventions 1 and 2 combined;
(4) the regular curriculum as control condition.
!!!Main outcome measures:
Incidence of (heavy) weekly alcohol use at 34 months (2009) after baseline measurement (2006).
!!!Results:
There were 2937 students eligible for analyses in this study. At follow-up, ''only the combined student–parent intervention showed substantial and signifıcant effects'' on heavy weekly and weekly drinking.
!!!Conclusions:
The short-term effects found in the present study further support that adolescents as
well as their parents should be targeted in order to delay the onset of (heavy) drinking.

@@ good Literature review on innovative methods to deliver alocohol interventions.@@
Innovative approaches to intervention for problem drinking
Kypros Kypri, Thiagarajan Sitharthan, John A. Cunningham, David J. Kavanagh and Johanna I. Deane
Current Opinion in Psychiatry 2005, 18:229–234
Conclusion (all quotes):
"This literature review demonstrates strong interest in
innovative methods of alcohol intervention to supplement
standard treatment in various health care settings or
to provide stand-alone intervention in the wider community.
There were few efficacy trials over the period, despite the lead given by the positive findings of previous trials (e.g. [34,37]). Correspondence-based interventions and telephone support studies had mixed results, although the study by Curry et al. [28]evaluating the treatment of insomnia with self-help materials and telephone support is promising.
The three efficacy trials on computerized interventions:
Schinke SP, Schwinn TM, Di Noia J, Cole KC. Reducing the risks of alcohol use among urban youth: three-year effects of a computer-based intervention with and without parent involvement. J Stud Alcohol 2004; 65:443–449 - A computerized primary prevention program assisting 10–12-year-olds to delay onset of drinking reduced alcohol use and delayed initiation to heavy drinking at 1, 2 and 3-year follow-ups compared with controls
...and ...
Kypri K, Saunders JB, Williams SM, et al. Web-based screening and brief intervention for hazardous drinking: a double-blind randomized controlled trial. Addiction 2004; 99:1410–1417. The study is the first the authors know of that examines the efficacy of e-SBI in a primary care setting. Patients of a university health service who received e-SBI reduced their consumption and related problems by 20–30% over 6 months relative to controls.
these studies indicate that these approaches can reduce hazardous alcohol consumption. Results showing delays in initiation to heavy drinking among younger adolescents receiving a CD-ROM intervention are particularly encouraging. The evaluation of innovative interventions for alcohol problems is still at a fledgling stage.
Existing studies need replication, and effort must be
made to conduct controlled trials in naturalistic conditions
to ensure generalizability of the findings to routine
healthcare delivery.

Assessment may conceal therapeutic benefit: findings from a randomized controlled trial for hazardous drinking
Kypros Kypri1,2, John D. Langley2, John B. Saunders3 & Martine L. Cashell-Smith2
Addiction, 102, 62–70
ABSTRACT
''Context''
The concept that assessment of a person’s health status without subsequent intervention has beneficial effects in itself has stimulated much interest in underlying psychological mechanisms, methodological implications and its public health potential. There have, however, been few experimental studies of assessment effects.
''Aim''
To test the hypothesis that assessment in itself produces a reduction in hazardous drinking.
''Design and setting''
Two conditions (group A, leaflet only and group B, leaflet and assessment but no intervention) of a four-arm randomized
controlled trial with enrolment in March–April 2003.
Participants A total of 975 students (17–29 years) (@@NB age range not really adolescent@@) attending a primary health-care clinic completed aweb-based Alcohol Use Disorders IdentificationTest (AUDIT) questionnaire. Of 599 who scored 8576 consented to follow-up and were included in the full four-arm trial, of whom 293 (153 women) were assigned to groups A and B. ''Intervention''
Group A received an information leaflet at baseline.
Group B received the information leaflet and 10 minutes of web-based assessment 4 weeks later.
''Measurements''
Drinking frequency, typical quantity, heavy episode frequency, personal problems and academic problems.
''Findings''
Baseline mean AUDIT scores were 15.0 (SD = 5.4) and 14.9 (SD = 5.0) in groups A and B, respectively.
Twelve months after baseline, relative to group A, group B reported lower overall consumption (geometric means ratio 0.82, 95% CI: 0.68–0.98), fewer heavy drinking episodes (0.66, 0.47–0.91), fewer problems (0.81, 0.67–0.99) and lower AUDIT
scores (beta = -1.63, -0.62 to -2.65).
''Conclusions''
Brief assessment appeared to reduce hazardous drinking. @@''Controlled trials that rely on assessment may therefore underestimate treatment effects''@@.
''Limitations''
include the possibility of measurement artefact due to social desirability bias.

Integrated Family and Cognitive-Behavioral Therapy for adolescent substance abusers: a Stage I efficacy study
William W. Latimer a,*, Ken C. Winters b, Thomas D’Zurilla c, Mike Nichols d
Drug and Alcohol Dependence 71 (2003) 303-317
CBS (alcohol)
A randomized controlled trial assessed youth
and parents at baseline and at 1, 3 and 6-month posttreatment points. Youth participants (N=43) met diagnostic criteria for one or
more psychoactive substance use disorders with most youth meeting criteria for alcohol and marijuana use disorders.
Integrated Family and CBT ([[IFCBT]]) Vs Psychoeducation (Drugs Harm Psychoeducation curriculum (DHPE))
Conceptual model of IFCBT:
(a) Problem-Focused Family Therapy addresses poor parenting and family pathology.
(b) Rational Emotive Therapy addresses irrational beliefs and psychiatric disorders.
(c) Problem Solving Therapy addresses neurocognitive deficits and deviant peer
networks.
(d) Learning Strategy Training addresses learning skill deficits and school failure.
Support for multi-systems approach.
Claims sensitive to neurocognitive vulnerabilities.
!!Gets 5star status for good planning (only stage I study)
Small numbers (159 refered to service, of which 104 appropriate, and 58 accepted entry to RCT)
Multiple measures +valid instruments
support for multisystems/FT integrated
!significantly better attendance at IFCBT
IFCBT youth attended significantly more sessions M= 26.67, SD = 13.31 than DHPE (M= 10.95, S.D = 4.4, p<0.001
DHPE used alcohol an average of 6.06 days
each month (SD = 7.15) which was significantly greater
than the average number of 2.03 days that IFCBT youth
used alcohol (S.D = 2.49) during the same period while
controlling for the potential confounding influences of
age, gender, total treatment sessions, and pretreatment
alcohol use frequency (F(1, 36) = 5.53, P<0.05)
Ditto CBS:
IFCBT produced significant reductions in
posttreatment marijuana use. Throughout the 6-month
posttreatment period, youth receiving DHPE used
marijuana an average of 13.83 days each month
(S.D=10.24) which was significantly greater than the
average number of 5.67 days that IFCBT youth used
marijuana (S.D.= 6.34) during the same period while
controlling for potential confounders (F(1, 36) =5.79,
P<0.05). Effect sizes moderate to strong from a 0.69 SD differnce between roups for the 4 - 6 month f/up period to a 0.74 SD difference between roups at 1 month follow up.
"The present study findings add to a small yet growing
base of literature in the adolescent treatment field that
suggests multi-systems treatments that engage youth
across multiple social systems may stand the best chance
of promoting drug abstinence (Henggeler et al., 1986;
Kaminer et al., 1998; Liddle et al., 2001; Szapocznik et
al., 1988)"

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|Version:|3.0.1 ($Rev: 2320 $)|
|Date:|$Date: 2007-06-18 22:37:46 +1000 (Mon, 18 Jun 2007) $|
|Source:|http://mptw.tiddlyspot.com/#LessBackupsPlugin|
|Author:|Simon Baird|
|Email:|simon.baird@gmail.com|
|License:|http://mptw.tiddlyspot.com/#TheBSDLicense|
!!Description
You end up with just backup one per year, per month, per weekday, per hour, minute, and second. So total number won't exceed about 200 or so. Can be reduced by commenting out the seconds/minutes/hours line from modes array
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Works in IE and Firefox only. Algorithm by Daniel Baird. IE specific code by by Saq Imtiaz.
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Liddle, H. A. (2002)
Advances in family-based therapy for adolescent substance abuse: findings from the Multidimensional Family Therapy research program.
In: Harris, L. S., ed. Problems of Drug Dependence 2001: Proceedings of the 63rd Annual Scientific Meeting. NIDA Research Monograph no. 182, NIH publication no. 02–5097, pp. 113–115.
Bethesda, MD: National Institute on Drug Abuse.
@@(Abstract seen only)@@
@@As described in [[Waldron and Kaminer 2004]]@@
In a second study, 224 adolescents referred for adolescent substance abuse in Philadelphia were randomly assigned to either @@multi-dimensional family therapy@@ or @@individual CBT@@.
The CBT //and// family interventions both included individual and conjoint family sessions.
However, the cognitive–behavioral condition emphasized self-monitoring, communication and problem-solving skills training, contingency contracting, and substance-refusal skills.
Substance use was measured using the time-line follow-back (TLFB) method, a calendar-based interview involving a daily reconstruction of drug use (Sobell & Sobell 1995).
Both interventions produced significant decreases in the percentage of reported substance use days during the past month from pretreatment to 6- and 12-month follow-up assessments, although there appeared to be continued improvement over time in the family therapy condition, compared to some leveling off in substance-use reductions in the CBT condition after the 6-month follow-up.
Again, Liddle and colleagues concluded that support for family therapy was relatively stronger, although the significant
within-condition pre- to post-treatment reductions in drug use for CBT provide some empirical support for this intervention as well.

J Psychoactive Drugs. 2004 Mar;36(1):49-63
Early intervention for adolescent substance abuse: pretreatment to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group treatment.
Liddle HA, Rowe CL, Dakof GA, Ungaro RA, Henderson CE.
RCT
Abstract:
This randomized clinical trial evaluated a family-based therapy and a peer group therapy with 80 urban, low-income, and ethnically diverse young adolescents (11 to 15 years) referred for substance abuse and behavioral problems. Both treatments were outpatient, relatively brief, manual-guided, equal in intervention dose, and delivered by community drug treatment therapists. Adolescents and their parents were assessed at intake to treatment, randomly assigned to either MDFT or group therapy, and reassessed at six weeks after intake and at discharge. Results indicated that the family-based treatment (MDFT, an intervention that targets teen and parent functioning within and across multiple systems on a variety of risk and protective factors) was significantly more effective than peer group therapy in reducing risk and promoting protective processes in the individual, family, peer, and school domains, as well as in reducing substance use over the course of treatment. These results, which add to the body of previous findings about the clinical and cost effectiveness of MDFT, support the clinical effectiveness and dissemination potential of this family-based, multisystem and developmentally-oriented intervention.

Liddle HA, Dakof GA, Turner RM, Henderson CE, Greenbaum PE. (2008) Treating adolescent drug abuse: a randomized trial comparing multidimensional family therapy and cognitive behavior therapy. Addiction. 2008 Oct;103(10):1660-70
AIM:
To examine the efficacy of two adolescent drug abuse treatments: individual cognitive behavioral therapy (CBT) and multidimensional family therapy (MDFT).
DESIGN:
A 2 (treatment condition) x 4 (time) repeated-measures intent-to-treat randomized design. Data were gathered at baseline, termination, 6 and 12 months post-termination. Analyses used latent growth curve modeling.
SETTING:
Community-based drug abuse clinic in the northeastern United States.
PARTICIPANTS:
A total of 224 youth, primarily male (81%), African American (72%), from low-income single-parent homes (58%) with an average age of 15 years were recruited into the study. All youth were drug users, with 75% meeting DSM-IV criteria for cannabis dependence and 13% meeting criteria for abuse.
MEASUREMENTS:
Five outcomes were measured: (i) substance use problem severity; (ii) 30-day frequency of cannabis use; (iii) 30-day frequency of alcohol use; (iv) 30-day frequency of other drug use; and (v) 30-day abstinence.
FINDINGS:
Both treatments produced significant decreases in cannabis consumption and slightly significant reductions in alcohol use, but there were no treatment differences in reducing frequency of cannabis and alcohol use. Significant treatment effects were found favoring MDFT on substance use problem severity, other drug use and minimal use (zero or one occasion of use) of all substances, and these effects continued to 12 months following treatment termination.
CONCLUSION:
Both interventions are promising treatments. Consistent with previous controlled trials, MDFT is distinguished by the sustainability of treatment effects.

National Youth Anti-Drug Media Campaign and school-based drug prevention: Evidence for a synergistic effect in ALERT Plus
Douglas Longshore, Bonnie Ghosh-Dastidara, Phyllis Ellickson
Addictive Behaviors 31 (2006) 496–508
4Stars for the intriguing question that it opens up.
Notion that there may be a SYNERGY between Psycho Educnt an the young person ALSO seeing the same info in national Media (confirming and rehearsing the message from the teaching...
''Abstract''
This analysis examined the @@possible synergistic effect of exposure to the National Youth Anti-Drug Media
Campaign and a classroom-based drug prevention curriculum@@ among 9th grade students participating in a
randomized trial of ALERT Plus.
A total of 45 South Dakota high schools and their middle-school feeder(s) were randomly assigned to an ALERT condition (basic prevention curriculum delivered in 7th and 8th grades), an ALERT Plus condition (basic curriculum with booster lessons added for 9th and 10th grades), or a control condition.
Marijuana use in the past month was significantly less likely among ALERT Plus students reporting at least weekly exposure to anti-drug media messages.
Quote from paper:
@@"Media messages consistently reflected the three themes of its communication
strategy-resistance self-efficacy, anti-drug norms, and negative consequences of use. Thus, the synergy
achieved between the Campaign and ALERT Plus was in substantive content as well as timing"@@
The National Youth Anti-Drug Media Campaign may have led to reductions in marijuana use among youth who simultaneously received school-based drug prevention.

See [[Liddle et al 2001]]
See also [[Henderson, Dakof et al 2010]]
Multi-dimensional family therapy (MDFT) (Dakof,
Tejeda & Liddle 2001; Liddle 2002a,b; Liddle
et al 2002) is a family-focused, developmentally-based treatment
that includes 12 weekly sessions (plus other telephone
and case management contact) to work individually with
the adolescents and their families on relationships inside
the family and on the adolescent’s relationships and functioning
in school and other social systems. Based on
NIDA-funded research studies and manuals, MDFT integrates
substance abuse treatment and a multiple systems
family therapy approach.
MDFT is an outpatient, family-based treatment
developed for adolescents with substance use and
related behavioral and emotional problems (Liddle,
1999; Ozechowski & Liddle, 2002). MDFT is delivered
in the home or community to facilitate accessibility to
treatment.
The MDFT approach combines aspects of several
theoretical frameworks, including family systems
theory, developmental psychology, ecosystems theory,
and the risk and protective model of adolescent substance
abuse.
MDFT is a comprehensive approach that works to
modify multiple domains of functioning by intervening
with the youth, family members, and other members of
the youth’s support network.
MDFT is designed to affect
multiple risk and protective factors. Treatment focuses on
four interdependent treatment
domains:
#adolescents,
#parents and other family members,
#family interactional patterns, and
#extrafamilial systems of influence
The four domains relate to empirically established areas of risk and
protection for youth and families, as well as knowledge
about the developmental psychopathology of adolescent
drug abuse (Liddle et al., 2000).
Each domain is considered critical to the change process, and MDFT therapists work
simultaneously in each domain according to the particular
risk and protection profile of the given adolescent and
family (Liddle, 2002b).
To accomplish this, the approach employs a variety of well supported
therapeutic techniques to improve the
behaviors, attitudes, and functioning across a variety of
domains (Liddle, 1999).
Three phases:
#ENGAGEMENT
#BEHAVIOURAL CHANGES
#GENERALIZING NEW SKILLS AND BEHAVIOURS AND MAINTENANCE
No follow up as part of intervention.

Motivational enhancement therapy/cognitive behavioral
therapy (MET/~CBT5) (Sampl & Kadden 2001) is a
five-session treatment composed of two individual sessions
of MET and three group sessions of CBT meeting
once per week. The MET sessions focus on factors that
motivate participants who abuse substances to change.
While in the CBT sessions, participants learn cannabis
refusal skills, how to increase their social support network
and non-drug activities and how to avoid or cope
with a relapse. Based on prior manuals funded by the
National Institute on Alcohol Abuse and Alcoholism
(NIAAA), NIDA and CSAT, it is designed to be a brief and
low-cost intervention that can be used as a first response
by managed care or an early intervention that could even
be delivered in non-clinical settings (e.g. as part of a
school assistance program).
''MET/~CBT5''
"MET/~CBT5 was an inexpensive first tier
intervention specifically designed for the 6-week median
length of stay that occurs in much of the U.S. treatment system.
The MET component proceeds from the assumptions
that adolescents need to: (a) resolve their ambivalence about
whether they have a problem with cannabis and other
substances, and (b) increase their motivation to stop using
cannabis. Therapists using MET seek to help adolescents see
the relationship between cannabis use and its consequences
so they will conclude that the costs of cannabis use outweigh
its benefits"
MET/CBT12
= additional 7 x CBT sessions:
Cognitive behavioral therapy 7 (CBT7) (Webb
et al 2002) is designed to follow MET/CBT5 with seven more
sessions of CBT focused on problem solving, awareness of
anger, anger management, receiving criticism, coping
with cravings, depression management, managing
thoughts about cannabis, planning for emergencies and
coping with relapse. Based on previously funded NIAAA
and CSAT research manuals, the combined protocol is
designed to cover many of the basic topics in modern substance
abuse treatment.

To address the multiple
needs of youth and families, MST uses a combination of
empirically supported intervention techniques based on
strategic family therapy, structural family therapy,
behavioral parent training, and cognitive behavior
therapy.
Akey element of MST is the focus on addressing complex
problems in a comprehensive, intense, and individualized
manner. Specifically, treatment is individualized in
that the family and the MST therapist work together to
target problems and select intervention strategies. MST
capitalizes on youth and family strengths, emphasizing
family empowerment and accessing needed family and
community resources. Moreover, the service delivery
model used with MST was developed with a focus on
increasing accessibility and engagement and minimizing
treatment dropout (T. A. Brown et al., 1999)

A Randomized Controlled Trial of an Emergency Department–
Based Interactive Computer Program to Prevent Alcohol Misuse
Among Injured Adolescents
Volume 45, no. 4 : April 2005 Annals of Emergency Medicine
@@ineffective@@ good study though.
Study objective: To determine whether an emergency department (ED)–based laptop computer
intervention reduces the normative age-related increase in alcohol misuse compared with standard of care.
Methods: This was a randomized controlled trial conducted from October 11, 1999, to April 14,
2001, in a community teaching hospital and university medical center. Subjects were aged 14 to 18
years and with a minor injury. Controls and intervention participants completed a computer-based
questionnaire. Intervention participants also completed a laptop-based interactive computer
program to affect alcohol misuse. Main outcome measures were Alcohol Misuse Index (Amidx) and
binge-drinking episodes. Follow-up occurred by telephone at 3 and 12 months. Analysis included
repeated-measures analysis of variance (a=0.05; power 0.80; effect size 0.10).
Results: Three hundred twenty-nine participants were randomized to the intervention group, and 326
participants were randomized to the control group. Two hundred ninety-five (89.7%) intervention
subjects and 285 (87.4%) control subjects completed 3- and 12-month follow-ups. For intervention
and control groups, respectively, mean age was 16.0 and 15.9 years and men composed 66.8% and
66.3% of the groups; Amidx scores were 2.2 and 2.0; binge-drinking episodes were 1.2 and 1.0.
Outcomes for intervention and control, respectively, were Amidx (3 months) 1.5 and 1.4; Amidx (12
months) 1.8 and 2.1; binge drinking (3 months) 0.9 and 0.8; and binge drinking (12 months) 1.4 and
1.2. Overall, there were no significant effects (effect size 0.04). No detrimental effects were noted.
Subgroup analysis suggested that the intervention may have an effect among subjects with
experience drinking and driving (5% of the sample).
Conclusion: The intervention was not effective in decreasing alcohol misuse among the study
population. Further research will be required to determine effectiveness among the subgroup of
adolescent minor injury patients who have experience drinking and driving. [Ann Emerg Med.
2005;45:420-429.]

Comparison of Pharmacological Treatments for Opioid-Dependent Adolescents ''A Randomized Controlled Trial''
Lisa A. Marsch, PhD; Warren K. Bickel, PhD; Gary J. Badger, MS; Marne E. Stothart, MA;
Kimberly J. Quesnel, MSW; Catherine Stanger, PhD; John Brooklyn, MD
Arch Gen Psychiatry. 2005;62:1157-1164
see [[O'Brien 2005]] for commentary.
To evaluate the relative efficacy of 2 pharmacotherapies, the partial opioid (Mu) agonist buprenorphine hydrochloride and the centrally active alpha2-adrenergic blocker clonidine hydrochloride, in the detoxification of opioid-dependent adolescents.
Why Buprenorphine? see [[Buprenorphine]]
Why Clonidine? see [[Clonidine]]
both groups got intensive behavioural intervention based on [[ACRA]] 3 x 1 hour per week by trained therpists
ContingencyMx - got vouchers for clean tests, upto $152 for continuous clean tests... and upto $20 for attnedance at sessions
Social ecology - encouraged to start new recreations, etc..
Naltrexone fiollow up option - could get Naltrexone if 3 x clean pee tests in last week (or had a onth to achieve this after finishing)...
!DB notes:
well generalizable - i.e. didnot exclude polysubstance users...
study design robust
Dosing regimen - note:
"flexible dosing procedure based on weight and self-reported opiate
use at intake. If participants were less than 70 kg and/or their
self-reported opiate use at intake was 1 to 3 bags of heroin @@NB NEED TO EXPLAIN THE VARIABILITY IN CONTENTS OF A "BAG"@@ or
the equivalent in other opiates, they were given a starting dose
of 6 mg of buprenorphine hydrochloride. If participants were
70 kg or more and/or their self-reported use was more than 3
bags of heroin or the equivalent in other opiates, they were given
a starting dose of 8 mg of buprenorphine hydrochloride. Buprenorphine
doses then decreased for participants in this condition
by 2 mg every 7 days. Because the maximum dose given
in the study was 8 mg and each tablet contained 2 mg of buprenorphine
hydrochloride, all participants were given a total
of 4 tablets daily composed of either active or placebo buprenorphine
hydrochloride."
Clonidine via transdermal pathch (@@Clonidine group got dummy Buprenorhone and Buprenorhine got dummy TD patches@@)
"On intake day and day 1, participants wore a single patch
of 0.1 mg of clonidine hydrochloride. A second patch of 0.1
mg was added on day 2 and worn for days 2 to 6 (resulting in
a 0.2-mg dose on these days). An optional third patch (depending
on the severity of withdrawal symptoms) may have been
added on day 4 and worn through day 6 (for a total of 0.3 mg
on these days). All patches were removed on day 7 and replaced
with a 0.2-mg dose. On day 14, all patches were again
removed and replaced with a 0.1-mg dose. On day 21, all patches
were removed and replaced with a 0-mg dose (placebo patch,
which looked identical to the active clonidine patch but did
not contain any active medication)"
Note that the main advatage is in RETENTION
"There were no significant differences in opiate use between the 2 groups among those adolescents who remained in treatment,
but the effects of buprenorphine in combination with behavioral therapy were clearly superior in retaining more of these young patients in the treatment program." - quote from [[O'Brien 2005]] commentary on this paper
ABSTRACT:
''Context:''
The prevalence of heroin and other opioid use has markedly increased among adolescents in the last decade; however, virtually no research has been conducted to identify effective treatments for this population.
''Objective:'' To evaluate the relative efficacy of 2 pharmacotherapies, the partial opioid agonist buprenorphine hydrochloride and the centrally active alpha2-adrenergic blocker clonidine hydrochloride, in the detoxification of opioid-dependent adolescents.
''Design, Setting, and Patients:''
A double-blind, double-dummy, parallel-groups randomized controlled trial conducted in a university-based research clinic from October 2001 to December 2003. Patients were a volunteer sample of 36 adolescents who met DSM-IV criteria for opioid dependence (ages 13-18 years eligible).
''Interventions:''
Participants were randomly assigned to a 28-day, outpatient, medication-assisted withdrawal treatment with either buprenorphine or clonidine. Both medications were provided along with thrice weekly behavioral counseling and incentives contingent on opiate abstinence. Postdetoxification, all participants were offered the opportunity for continued treatment with the opiate antagonist, naltrexone hydrochloride.
''Main Outcome Measures:''
Treatment retention, opiate abstinence, and human immunodeficiency virus risk behavior, along with measures of withdrawal and medication effects.
''Results:''
A significantly greater percentage of adolescents who received buprenorphine were ''retained in treatment'' (72%) relative to those who received clonidine (39%) (P< 0.05). For those in the buprenorphine group, a significantly higher percentage of scheduled ''urine test results were opiate negative'' (64% vs 32%; P=.01).
Participants in both groups reported relief of withdrawal symptoms and drugrelated human immunodeficiency virus risk behavior. Those in the buprenorphine condition generally reported more positive effects of the medication. No evidence
of opioid intoxication or psychomotor impairment was observed.
''Sixty-one percent of participants in the buprenorphine condition and 5% of those in the clonidine group initiated treatment with naltrexone.''
''Conclusion:''
Combining buprenorphine with behavioral interventions is significantly more efficacious in the treatment of opioid-dependent adolescents relative to combining clonidine and behavioral interventions.
''FUNDING'' -
This study was sponsored by grant R03
DA 14570 and R01 DA 12997 from the National Institute
on Drug Abuse, Bethesda, Md, and research funds
from the Department of Psychiatry and the College of
Medicine at the University of Vermont, Burlington. NOT PHARMA!!!

Cocaine and crack cocaine, Ecstasy - M.I. not helpful
"Brief (single sessions) motivational intervention. "
"Our adapted model was based on a sequential set of topic
strategies for delivery by youth drug workers who, overall,
would have relatively limited counselling experience
and skills. We judged that a single session would be the
most acceptable form of intervention among a target population
which is recognized to be a difficult group to
engage and where there are likely to be considerable differences
in the perceived need for behaviour change [25]."
Single session AIMS (Assest, Information Motivation and Support) - adapted M.I.
342 x (16-22 )yrs ….E, coke or crack users (self idientified. )
Excluded past injectors.
Manualised, trained therapists, monitoring...
randomised, control (87% ctive Rx and 88% control followed up at 6/12)
"No differneces found between information-giving (control) and M.I. intervention."
However more intervention pts said they had ""tried to give up"" (unsuccessfully, it seems) RR of 1.47 for this Vs Control…
fits with two previous studies in adults that also found no benefit in brief MI intervention for these drugs: Miller W. R., Yahne C. E., Tonigan J. S. Motivational interviewing in drug abuse services: a randomized trial. J Consult Clin Psychol 2003; 71: 754–63. Donovan D. M., Rosengren D. B., Downey L., Cox G. C., Sloan K. L. Attrition prevention with individuals awaiting publicly funded drug treatment. Addiction 2001; 96: 1149–60."

!it's not so much what's inside your head, it's what your head's inside of...
Direct realism - Gibson (1950) that the world is real and can be directly perceived as such...
Role of illusions in understanding addiction...
Most people relate to the //language of addiction...//
Risk of pathologising nature of language, stereotypes; so that behaviour is excused by virtue of addiction...
!Causal models and Reasons models
* Causes and correlates of adolescent drug abuse and implications for treatment. Spooner C. drug and alcohol review 1999, 18, 4.
* The allure of neuroscience explanations, J cognitive neuroscience 2008: 20:3 pp 470-477
Very difficult to pull out clear descriptions of "causal parenting"! Multiple studies have already shown what are the protective factors...
But we can't just "alter the environment" to stop adolescent drug use.... And these studies very rarely talk to the young people abouth WHY they are using drugs..
Main REASON given by young people are to get to sleep!
Multivariate risk factors - but MASSIVE variance between different studies looking at these!
!"The meaning of addiction" by Stanton Peele
The dominant addiction model is biological and genetic, and bypasses asking and talking to humans...
But most addicts give up or reduce their use in relation to LIFE needs/events...
!the effect of housing and gender on morphine self administration in rats. Alexander BK Et al Pharmacology, 1978.
Created "rat park" to offer morphine and non-morphine use in different social settings for rats (rather than rats alone in cages)
Caged rats take to morphine very quickly, but rats in rat park always resisted it in favour of plain water, preferring to socialise...
Severely distressed animals, like severely distressed people will seek to relieve their distress....
Insanity - the rational response to an insane world... RD Laing
!Growing out of trouble - Monty Don

McCambridge J, Strang J. (2004) The efficacy of single-session motivational interviewing in reducing drug consumption and perceptions of drug-related risk and harm among young people: results from a multi-site cluster randomized trial. Addiction. 2004 Jan;99(1):39-52.
CBS. Alc, polydrug NB see 2005 follow-up study - BENEFITS DISAPPEAR at 1 year!!!
Single session M.I. for 200 young people recurit ed in naturalistic way.
Randomised Trial - to M.I or Educational package
Single one hour session of MI Vs 1 hour TAU (drugs Education)
200 YP aged 16-20 from 10 FE colleges acriss London
Follow up at 3/12. (89.5% follow up rate - 179/200 - good)
Cluster randomisatoion.
Recruitment via "peer interviewers" who had 'privileged access'. Cluster = the group recruited by that interveiwer (£10 per interveiw completed for participants) Clusters randomised (stratified by college to rule out effects of local drug use patterns)...
M.I. n= 105, and TAU = 95.
Criteria:
Participants had to be < 20 with current illegal drug use. NOT opiate and injecting drug use ("deemed to be a separate population") consented for hair analysis and sample taken (not intended for use) - to increase accuracy of self report. Blinded interviewer did sample of follow up interviews to counter bias by JMcC (interventionist) doing interviews
Strong study design.
Randomised Controlled (TAU) trial,
Various measures incl Severity of Dependence Scale (SDS), measures of interational problems, (drug sellling, pub/club going, intoxicated arrest, beong offered heroin, being present at heroin use and injecting drug use….) Drug attitude scale, etc… NB risk of Type I errors from so many outcome measures (higher chance of one finding positive results by chance)
Showed postive effects of single session - especially in high vulnerability and higher usage groups....NB contradicted in [[Stein et al 2006]] more in MODERATING use than leading to abstinence (HARM REDUCTION)
"In comparison to the control group, those randomized to motivational interviewing reduced their of use of cigarettes, alcohol and cannabis, mainly through moderation of ongoing drug use rather than cessation.
Effect sizes were 0.37 (0.15–0.6), 0.34 (0.09–0.59) and 0.75 (0.45–1.0) for reductions in the use of cigarettes, alcohol and cannabis, respectively. For both alcohol and cannabis, the effect was greater among heavier users of these drugs and among heavier cigarette smokers. The reduced cannabis use effect was also greater among youth usually considered vulnerable or high-risk according to other criteria."
...BUT - only 3/12 follow up - ony small no.s reporting use of drugs other than CBS, so difficult to draw inferenes about their responses, data self reported - no biochemical markers...
NB see 2005 follow-up study - BENEFITS DISAPPEAR at 1 year!!!

McCambridge J, Strang J. (2005) Deterioration over time in effect of Motivational Interviewing in reducing drug consumption and related risk among young people. Addiction. 2005 Apr;100(4):470-8.
!Abstract
!!AIM:
To test whether beneficial effects of a single session of Motivational Interviewing (MI) on alcohol, tobacco and illicit drug use apparent after 3 months were maintained until 12 months.
!!DESIGN:
Cluster randomized trial, allocating 200 young people in the natural groups in which they were recruited to either MI (n = 105) or to an assessment-only control condition (n = 95).
!!SETTING:
Ten further education colleges across inner London.
!!PARTICIPANTS:
Two hundred young people who were current users of illegal drugs (age range 16-20 years) with whom contact was established through peers trained for the project.
!!INTERVENTION:
The intervention was adapted from MI in the form of a topic-based 1-hour single-session discussion.
!!MEASUREMENTS:
Changes in cigarette, alcohol, cannabis and other drug use and perceptions of risk and harm between the time of recruitment and follow-up interviews after 3 and 12 months.
!!FINDINGS:
A satisfactory follow-up rate (81%) was achieved. After 12 months, 3-month differences between MI and assessment-only groups have disappeared almost entirely. Unexpected improvements by the assessment-only control group on a number of outcomes suggest the possibility of reactivity to the research assessment at 3-month follow-up.
!!CONCLUSION:
In the terms of the original experiment, there is little evidence of enduring intervention effectiveness shown by between-group differences after 12 months. Deterioration of effect is the most probable explanation, although reactivity to 3-month assessment, a late Hawthorne effect, cannot be ruled out.
Comment in: Addiction. 2005 Apr;100(4):421.
!DB comments/notes
long term (12/12) f-up study to [[McCambridge and Strang 2004]] paper
"positive Rx effects at 3/12 had disappeared at 12/12." (Except for proneness to be in company of heroin use, which remained a positive effect in the Rx group)
??Late Hawthorn Effect? The main assessment interview was at 3/12 (not at baseline) and was 30-45 mins - as long as the intervention itself... could this have casued unplanned for effects in itself?
From McCambridge: "The seminal report by Russell et al. (1979) contained the
overlooked finding that more participants, for whom
abstinence was biochemically validated after 1 year, actually
quit smoking in the month immediately preceding
the research interview than had quit in the month following
brief intervention. When dedicated studies have
been undertaken to estimate the size of these effects in
treatment studies they have been found to be large (Clifford
et al. 2000). More than a decade ago, Bien et al.
(1993), proposed the employment of Solomon fourgroup
designs in order to separate and estimate precisely
the effects of assessments and brief interventions. To our
knowledge, this call has gone unheeded."

McCambridge J, Hunt C, Jenkins RJ, Strang J (2011) ''Cluster randomised trial of the effectiveness of Motivational Interviewing for universal prevention''. Drug and Alcohol Dependence 114 (2011) 177–184
!Abstract
!!!Background:
The ''__prevention of initiation of tobacco, alcohol and drug use__'' is a major societal challenge, for which the existing research literature is generally disappointing.
This study aimed to test the effectiveness of adaptation of Motivational Interviewing (MI) for universal prevention purposes, i.e. to prevent initiation of new substance use among non-users, and to reduce risks among existing users.
!!!Methods:
Cluster randomised trial with 416 students aged 16–19 years old recruited in 12 London Further Education colleges without regard to substance use status.
Individualised MI was compared with standard practice classroom-delivered Drug Awareness intervention, both delivered over the course of one lesson.
Prevalence, initiation and cessation rates for the 3 target behaviours of cigarette smoking,
alcohol consumption and cannabis use, along with reductions in use and harm indicators after both 3 and 12 months were assessed.
!!!Results:
This adaptation of MI was not demonstrated to be effective in either intention-to-treat or subgroup analyses for any outcome.
Unexpected lower levels of cannabis initiation and prevalence were found in the Drug Awareness control condition.
!!!Conclusions:
This particular adaptation of MI is ineffective as a universal drug prevention intervention
and does not merit further study.

Author: J. McCambridge, C. Hunt, R. J. Jenkins and J. Strang
Year: 2011
Title: Cluster randomised trial of the effectiveness of Motivational Interviewing for universal prevention
Journal: Drug and Alcohol Dependence
Volume: 114
Issue: 2-3
Pages: 177-184
Abstract:
!Background:
The prevention of initiation of tobacco, alcohol and drug use is a major societal challenge, for which the existing research literature is generally disappointing.
This study aimed to test the effectiveness of adaptation of Motivational Interviewing (MI) for universal prevention purposes, i.e. to prevent initiation of new substance use among non-users, and to reduce risks among existing users.
!Methods:
Cluster randomised trial with 416 students aged 16-19 years old recruited in 12 London Further Education colleges without regard to substance use status. Individualised MI was compared with standard practice classroom-delivered Drug Awareness intervention, both delivered over the course of one lesson. Prevalence, initiation and cessation rates for the 3 target behaviours of cigarette smoking, alcohol consumption and cannabis use, along with reductions in use and harm indicators after both 3 and 12 months were assessed.
!Results:
This adaptation of MI was not demonstrated to be effective in either intention-to-treat or sub-group analyses for any outcome. Unexpected lower levels of cannabis initiation and prevalence were found in the Drug Awareness control condition.
!!Conclusions:
This particular adaptation of MI is ineffective as a universal drug prevention intervention and does not merit further study.

McGrath J, Welham J, Scott J, Varghese D, Degenhardt L, Hayatbakhsh MR, Alati R, Williams GM, Bor W, Najman JM.
!Association between cannabis use and psychosis-related outcomes using sibling pair analysis in a cohort of young adults.
Arch Gen Psychiatry. 2010 May;67(5):440-7. Epub 2010 Mar 1.
!Abstract
!CONTEXT:
Prospective cohort studies have identified an association between cannabis use and later psychosis-related outcomes, but concerns remain about unmeasured confounding variables. The use of sibling pair analysis reduces the influence of unmeasured residual confounding.
!OBJECTIVE:
To explore the association between cannabis use and psychosis-related outcomes.
!DESIGN:
A sibling pair analysis nested within a prospective birth cohort.
!SETTING:
Births at a Brisbane, Australia, hospital.
!PARTICIPANTS:
Three thousand eight hundred one young adults born between 1981 and 1984 as part of the Mater-University Study of Pregnancy.
!MAIN OUTCOME MEASURES:
Cannabis use and 3 psychosis-related outcomes (nonaffective psychosis, hallucinations, and Peters et al Delusions Inventory score) were assessed at the 21-year follow-up. Associations between duration since first cannabis use and psychosis-related outcomes were examined using logistic regression adjusted for sex, age, parental mental illness, and hallucinations at the 14-year follow-up. Within 228 sibling pairs, the association between within-pair differences in duration since first cannabis use and Peters et al Delusions Inventory score was examined with general linear modeling. The potential impact of attrition was examined.
!RESULTS:
Duration since first cannabis use was associated with all 3 psychosis-related outcomes. For those with duration since first cannabis use of 6 or more years, there was a significantly increased risk of (1) nonaffective psychosis (adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.5), (2) being in the highest quartile of Peters et al Delusions Inventory score (adjusted odds ratio, 4.2; 95% confidence interval, 4.2-5.8), and (3) hallucinations (adjusted odds ratio, 2.8; 95% confidence interval, 1.9-4.1). Within sibling pairs, duration since first cannabis use and higher scores on the Peters et al Delusions Inventory remained significantly associated.
!CONCLUSIONS:
Early cannabis use is associated with psychosis-related outcomes in young adults. The use of sibling pairs reduces the likelihood that unmeasured confounding explains these findings. This study provides further support for the hypothesis that early cannabis use is a risk-modifying factor for psychosis-related outcomes in young adults.

What does it take to retain substance-abusing adolescents in research protocols? Delineation of effort required, strategies undertaken, costs incurred, and 6-month post-treatment differences by retention difficulty
Kathleen Meyers a,b,*, Alicia Webb a, Jeanne Frantz a, Mary Randall
Drug and Alcohol Dependence 69 (2003) 73-85
Not an RCT - interesting question and sheds light on the POOR PROGNOSIS OF THE HARDEST TO REACH
Looked at sample from a larger study of in-pt Rx (CASI study) - tracked efforts to keep youths enrolled and followed up, and looked at different profiles of hard-to-reach adoelscents cf the easy to reach ones
The results suggest that high retention rates among substance-abusing adolescent research participants:
(1)can be achieved
(2)require persistence (over 40% of youth required six or more contact attempts prior to completing an interview);
(3) entail a menu of follow-up strategies and methodologies; and
(4) call for an inperson interview at a time and place convenient, familiar, and neutral to the adolescent.
Significantly more of the difficult-to-retain youth reported serious delinquent and offending behavior, and AOD, family, and educational problems at 6-months post-treatment discharge. If the difficult-to-retain group was not pursued, a positively skewed picture of functioning 6-months after treatment would have been obtained within the AOD, family, educational, and juvenile justice domains.

Delinquent Behavior and Emerging Substance Use in the MTA at 36 Months: Prevalence, Course, and Treatment Effects
BROOKE S.G. MOLINA, PH.D., KATE FLORY, PH.D., STEPHEN P. HINSHAW, PH.D.,
ANDREW R. GREINER, B.S., L. EUGENE ARNOLD, M.D., JAMES M. SWANSON, PH.D.,
LILY HECHTMAN, M.D., PETER S. JENSEN, M.D., BENEDETTO VITIELLO, M.D.,
BETSY HOZA, PH.D., WILLIAM E. PELHAM, PH.D., GLEN R. ELLIOTT, PH.D., M.D.,
KAREN C. WELLS, PH.D., HOWARD B. ABIKOFF, PH.D., ROBERT D. GIBBONS, PH.D.,
SUE MARCUS, PH.D., C. KEITH CONNERS, PH.D., JEFFERY N. EPSTEIN, PH.D.,
LAURENCE L. GREENHILL, M.D., JOHN S. MARCH, M.D., M.P.H.,
JEFFREY H. NEWCORN, M.D., JOANNE B. SEVERE, M.S., AND TIMOTHY WIGAL, PH.D.
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:8, AUGUST 2007
ABSTRACT
Objective: To compare delinquent behavior and early substance use between the children in the Multimodal Treatment
Study of Children With ADHD (MTA; N = 487) and those in a local normative comparison group (n = 272) at 24 and 36
months postrandomization @@and to test whether these outcomes were predicted by the randomly assigned treatments and
subsequent self-selected prescribed medications.@@
Method:
Most MTA children were 11 to 13 years old by 36 months. Delinquency seriousness was coded ordinally from multiple measures/reporters; child-reported substance use was binary.
@@NB see the earlier study by [[Biederman et al 1999]]@@
Results:
''Relative to local normative comparison group'', MTA children had significantly higher rates of delinquency (e.g., 27.1% vs. 7.4% at 36 months; p = .000) and substance use (e.g., 17.4% vs. 7.8% at 36 months; p = .001).
Children randomized to ''intensive behavior therapy'' reported ''less 24-month substance use'' than other MTA children (p = .02).
Random effects ordinal growth models revealed no other effects of initial treatment assignment on delinquency seriousness or substance use. ''By 24 and 36 months, more days of prescribed medication were associated with more serious delinquency but not substance use.''
''Conclusions:''
Cause-and-effect relationships between medication treatment and delinquency are unclear; the absence of associations between medication treatment and substance use needs to be re-evaluated at older ages. Findings underscore the need for continuous monitoring of these outcomes as children with attention deficit/hyperactivity disorder enter adolescence.
"Children who received intensive behavior therapy (Beh+Comb) reported less substance use by 24 months than the children who did not (MedMgt+CC). There were @@no other effects of initial treatment assignment (MedMgt, Beh, Comb, or CC)@@ on growth in delinquency over time, level of delinquency seriousness posttreatment, or substance use by the 24- and 36-month follow-ups. Self-selected prescription medication treatment after 14 months was positively related to delinquency seriousness: @@children with more serious offenses were more likely to be medicated after the end of study-delivered treatment. No association was observed for early substance use.@@
@@We did not find evidence of protective or adverse effects of medication treatment for ADHD, either study delivered or self-selected, on the initiation of substance use at this young age.@@ This null finding has been previously reported for roughly this age range, in the Chilcoat and Breslau (1999) sample at age 11, and in the Developmental Trends Study for boys 13 to 15 years old (Burke et al., 2001).
"...in addition to comparing early substance use between the MTA and our local normative comparison group (LNCG), an important clinical question is whether treatment history, either randomly assigned or self-selected, is associated with emerging substance use in early adolescence."
!DB: NB association of 'worse outcomes in the MTA kids is not the same as saying that 'Rx makes kids worse' - on the contrary - the association with higher rates of CD in those most in drug-Rx signals how these high risk kids are the ones that most trigger medication as a Rx response as nothing else works...

Safety and Efficacy of the Nicotine Patch and Gum for the Treatment of Adolescent Tobacco Addiction
Pediatrics 2005;115;e407-e414
ABSTRACT.
"''Objectives''.
To determine the safety and efficacy of the nicotine patch and gum for adolescents who want to quit smoking.
''Design.''
Double-blind, double-dummy, randomized, 3-arm trial with a nicotine patch (21 mg), nicotine gum (2and 4 mg), or a placebo patch and gum; all participants received cognitive-behavioral group therapy.
''Setting.''
Inner-city, outpatient clinic on the East Coast.
''Subjects.''
Thirteen- to 17-year-old adolescents who smoked >10 cigarettes per day (CPD), scored >5 on the Fagerstro¨m Test of Nicotine Dependence, and were motivated to quit smoking.
''Intervention.''
Twelve weeks of nicotine patch or gum therapy with cognitive-behavioral therapy, with a follow-up visit at 6 months (3 months after the end of treatment).
''Main Outcome Measures''.
#Safety assessed on the basis of adverse event reports for all 3 groups,
#Prolonged abstinence, assessed through self-report and verified with exhaled carbon monoxide (CO) levels of <6 ppm, in intent-to-treat analyses, and smoking reduction (CPD and thiocyanate concentrations) among trial completers.
''Results.''
A total of 120 participants were randomized
(72% white, 70% female; age: 15.2 +/- 1.33 years; smoking: 18.8 +/- 8.56 CPD; Fagerstrom Test of Nicotine Dependence
score: 7.04 +/- 1.29) from 1999 to 2003. Participants started smoking at 11.2 +/- 1.98 years of age and had been smoking daily for 2.66 +/- 1.56 years; 75% had at least 1 current psychiatric diagnosis.
Mean compliance across groups was higher for the patch (mean: 78.4–82.8%) than for the gum (mean: 38.5–50.7%).
Both the patch and gum were well tolerated, and adverse events were similar to those reported in adult trials.
Changes in mean saliva cotinine concentrations throughout treatment were not statistically significant. @@Intent-to-treat analyses of all randomized participants showed CO-confirmed prolonged abstinence rates of 18% for the active-patch group, 6.5% for the active-gum group, and 2.5% for the placebo group; the difference between the active-patch and placebo arms
was statistically significant@@.
There was no significant effect of patch versus gum or gum versus placebo on cessation outcomes ("The odds ratio (OR) of prolonged abstinence for the patch group, compared with the placebo group, was 8.36 (95% confidence interval [CI]: 0.95–73.3; P<0.055) and that for the gum group, compared with the placebo group, was 2.72 (95% CI: 0.27–27.3; P< 0.39);")..@@DB: (trend but not quite reaching significance)@@....@@("The large effect size (OR: 8.36) for the comparison of the patch versus
placebo for prolonged abstinence suggests a clinically significant effect; however, the wide CI (95% CI: 0.95–73.3) indicates a lack of statistical power.)@@
Abstinence rates at the 3-month follow-up assessment were sustained but were not significantly associated with treatment group.
Mean smoking rates, but not CO or thiocyanate concentrations, decreased significantly in all 3 arms but not as a function of
treatment group.
Conclusions.
@@Nicotine patch therapy combined with cognitive-behavioral intervention was effective, compared with placebo, for treatment of tobacco dependence among adolescent smokers.@@
Decreases in the numbers of cigarettes smoked appeared to be offset by compensatory smoking. Additional study of nicotine gum, with enhanced instructional support, is needed to assess its efficacy among adolescent smokers."
!DB notes:
recruited via adverts in schools and churches - telephone interveiw as pre-screen -> progress to on-site interview and examination: "Adolescents 13 through 17 years of age who were in general good health, had smoked >10 cigarettes per day for >6 months, had a minimal score of 5 on the Fagerstrom Test of Nicotine Dependence (FTND), and were motivated to stop smoking were eligible to participate"...
@@signif pruning of applicants -> final participants@@:
"Of 1347 adolescents who telephoned the clinic in
response to advertisements, 329 were preeligible in
telephone screenings and 159 presented for on-site
screening, as described in a separate report.33 Of the
159 adolescents who presented for enrollment, 39
(24.5%) were not randomized, after on-site evaluations
indicated their ineligibility..."
2 x baseline clinic visits then quit date set a week ahead of that (randomised to three Rx arms)
@@Comorbidity was high:@@ (realistic sample in that taking cincurrent meds for other disirders was not an exclusion criterion)
"90 subjects (75%) had at least 1 current psychiatric diagnosis,
according to the Diagnostic Interview for
Children and Adolescents.28 The most frequently
represented categories were oppositional defiant disorder
(40%), conduct disorder (15%), attention-deficit/
hyperactivity disorder (current: 7%; previous:
11%), and premenstrual dysphoric disorder (11%)."
High Attrition rate (similar to [[Hanson et al 2003]])..."Although our
attrition rate of 54% was high, it had been anticipated
and was comparable to the 61% dropout rate recently
reported for adolescent participants who attended
trial visits at a research office. ([[Hanson et al 2003]])"
!FUNDING:
This work was supported by funds from the National Institute
on Drug Abuse, Intramural Research Program.
@@We thank GlaxoSmithKline (Research Triangle Park, NC) for
providing us with study medications (21- and 14-mg Nicoderm, 2-
and 4-mg Nicorette, and placebo patch and gum).@@ This trial would
not have been possible without the support of the Teen Tobacco
Addiction Treatment Research Clinic staff, including

Looking at data from the SAMSHA/CSAT studies (11 funded in 1998 and 1999) in the ATM (Adolescent Treatment Models) programme.
This report describes RAND Corporation’s approach to this problem, and our findings concerning the relative effectiveness of the 11 programs evaluated under ATM:
#three ''long-term residential (LTR) facilities'' (Dynamic Youth Community, Inc., in New York; Phoenix Academy of Los Angeles; and Thunder Road in Oakland), modified therapeutic communities, upto c. 1 year treatment...
#four ''short-term residential (STR) facilities'' (La Cañada in Tucson; Mountain Manor in Baltimore; Our Youth Our Future in Shiprock, New Mexico; and Thunder Road in Oakland), c 30 day residential package with outpatient follow up - variety of interventions - Family, individual, milieu, some designed specifically for ethnic sub-groups (N american Indians, etc)
#four ''outpatient (OP) programs''(Chestnut Health Systems in Bloomington, Illinois; Epoch Counseling Center in Baltimore County; Teen Substance Abuse Treatment in Maricopa County, Arizona; and The Village in Miami), include Chestnut who have two OP programmes, standard and intensive, variety of FAmily/iundiv programmes. The Village (Liddle et al) had too few cases registered to inclue in analysis here.
Because of the small number of cases available for analysis at one ATM outpatient program, treatment effect estimates were not calculated for it.
@@weighting system to adjust for pre-treatment differnces between patients admitted to diff programmes at the same level of care@@
When considering these 86 important pretreatment measures, the various programs appear to
be serving distinctly different populations. Before weighting there were large and significant
differences between every target program and its corresponding comparison programs. These
differences were often for clearly important variables such as pretreatment substance use and
the use of needles and opiates. Weighting by the propensity scores removes many of these differences
but after weighting, several target programs continued to differ from their comparison
group on potentially important risk factors. - @@Often difficult to attain the power to identify what are quite small differnces in effect sizes between programmes@@
"The findings of this report are similar to those reported from the Cannabis Youth Treatment project (Dennis et al., 2004) and Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity) (Project Match Research Group, 1997). @@Specifically, differential treatment effects are not found, even though programs are compared, in some cases, to interventions involving fairly minimal treatment@@"
might be because all the studied groups were accepted because they are in some way exemplary...
our @@failure to find strong and persuasive evidence of treatment effectiveness@@
could indicate that we were looking for that evidence in the wrong place. Large and significant treatment effects might exist for each evaluated treatment program, but these might be no longer detectable 12 months after treatment admission. McLellan et al. (2005) have argued, for instance, that for chronic, relapsing conditions like substance abuse, the treatment effects
of interest are chiefly those observed during treatment. By analogy, they note that treatments for other chronic conditions, like diabetes or schizophrenia, are typically evaluated in terms of symptom management during treatment, not by whether or not such benefits remain detectable long after treatments are withdrawn...
''Methodological/sample problems:''
#case mix adjustment - who is accepted into programmes under study...
#rates of follow up data collection - high percentage vs low percentage
#rates of institutionalisation post Rx - (difficult to estimate effectiveness if a youngster is in prison and unable to access drugs!) - see [[Godley et al 2004]]
#@@''In this report, no program was found to consistently outperform any other, across outcomes. Indeed, few program differences were noted on any outcome, even though 70 percent of these analyses had sufficient power to detect effect sizes of 0.40 or greater.''@@ - would need larger sample sizes to get the power to distinguish smaller outcome differences
#SOME of the kids in the long term rehab settings were STILL IN Rx at the time of the 12/12 "follow up" measures... these are still measured as "outcomes"...
''SAMPLE:''
"Because we wish to examine treatment effects 12 months post-admission, the sample was restricted to just those 1,545 cases with completed 12-month assessments."
''OUTCOME MEASURES:''
#recovery, (a dichotomous measure indicating that the youth is living in the community and experiencing few symptoms of substance use, abuse, or dependence. Specifically, recovery is 1 if the respondent is not in detention at the time of the interview, has not been in any other controlled environment for more than 15 of the last 90 days, and reports no symptoms of substance abuse or dependence in the past month.)
#substance problems, (measured via GAIN)
#substance use frequency,(measured via GAIN)
#illegal acts,(measured via GAIN)
#emotional problems,(measured via GAIN)
#time in controlled environments (measured via GAIN)
@@''Minimal postive findings:''@@
"Across the 66 program and outcome pairings, only 11 statistically significant treatment effects were observed, and the
target facility had a positive effect relative to the comparison facilities in only five of these pairs.
In these pairs, adolescent outcomes following treatment in the target facility were better than those of comparable cases in the comparison facility. The remaining statistically significant effects were negative. That is, adolescent outcomes following treatment in the target facility were worse than those of comparable cases in the comparison facility, which does not imply that outcomes were worse than they would have been without treatment..."

For interventions directed at more than one level/dimension/system
i.e.
#Combinations of therapies (FT and CBT , or MET and CBT, for instance)
#A conceptually unitary therapy that is nonetheless directed at different settings/constituent parts of the milieu, designed to address multiple domains/dimensions simultanesoulsy (i.e MDFT, MST, CRA, EBFT)

Trials pitting different therapies against each other

! A Uni-dimensional construct
No longer abuse, or dependent use
Single category of use disorder - mild, moderate, severe
!11 Criteria:
1. Increasing volume of substance use, or using it for longer than initially intended
2. Wanting (and failing) to cut down or stop use.
3. Spending a lot of time accessing, using, or recovering from use.
4. Cravings to use the substance
5. Negative functional impact (at work, home or school) because of use.
6. Continued use, despite relationship problems it causes.
7. Withdrawal from important social, occupational, recreational activities in exchange for use
8. Continued use despite knowledge of associated danger
9. Continued use, despite acknowledgement that physical/psychological problems are being caused or exacerbated by this.
10. Requiring more of the substance to achieve the desired effects (tolerance)
11. Presence of withdrawal symptoms (relieved by using more).
!Contraversy:
Mislabled As Alcoholic?
According to the new criteria, a college student who binge drinks on weekends and occasionally misses a class would be diagnosed with mild alcohol abuse disorder. And this is where the controversy lies, according to critics of the manual revisions.
Critics say the revised criteria could lead to college or underage binge drinkers to be mislabeled as mild alcoholics, a diagnosis the could follow them into their later years.
Dr. Allen Frances, who chaired the task force that wrote the earlier edition of the DSM, said, //“The DSM-5 decision to lump beginning drinkers with end-stage alcoholics was driven by researchers who are not sensitive to how the label would play out in young people’s lives.”// (Quoted in TIME)
!Cautious Support:
[[Edwards, et al (2013) Assessment of a Modified DSM-5 Diagnosis of Alcohol Use Disorder]]

patches

<<tag [[Neuroscience of addiction]]>>

Mental health outcomes following naltrexone implant treatment for heroin-dependence
Hanh T.T. Ngo⁎,1, Robert J. Tait 2, Diane E. Arnold-Reed 3, Gary K. Hulse
Progress in Neuro-Psychopharmacology & Biological Psychiatry 31 (2007) 605–612
Retrospective cohort study, ''addressing the effectiveness of Naltrexone implants, especially in relation to concerns that they may contribute to depression/other MH probs in users''
("Of particular interest is the suggestion that naltrexone is associated with depression or dysphoria, possibly through its antagonistic action on both exogenous and endogenous opioids receptors")
@@primarily an adult study@@ -
''Participants:''
total of 359 patients considered in this study,
143 (39.8%) were females, with minimum age being 16.0 years and maximum 50.3 years (mean=26.7, SD=7.95).
Males’ age ranged from 16.8 to 53.0 years (mean=28.5, SD=7.19). The median of
the sex-combined age distributionwas 26.1 and inter-quartile range 22.2–31.2 years.
Measured clinical records of admission, mortality and morbidity data records - both pre-Rx (back to the 1960's) and post Treatment, for a sample of patients treated between 2001-2002 with Naltexone Implants (Go Medical 2.2 g naltrexone
implant, fitted at a private community-based drug treatment clinic in Perth, Western Australia.)
!Results:
"...there was strong indication that @@young, female users, or those with pre-existing mental illness were more vulnerable to mental health admissions following treatment.@@ These findings strongly emphasise the need for the potential patient to be sufficiently psychosocially prepared and supported prior to and during treatment, as well as to have their mental status closely monitored, especially in the earlier stage of treatment. Such cautions are particularly important when treatment involves the more vulnerable patient groups."
''Pre-existing mood disorder history'' or
''being relatively young at the time of treatment'' generally increased the risk of experiencing a mood disorder following implant treatment. However, unfavourable effects of prior history decreased with older age at treatment. For example, between two otherwise similar patients aged 22 years at treatment, the odds ratio (of one with history versus one without) was approximately 3.57; however, at age 31 when treated, the odds ratio decreased to .925.
!''FUNDING''
"This research was supported by the National Health
and Medical Research Council (353545) and the Office of
Mental Health, Department of Health Western Australia."

Comparison of disulfiram and placebo in treatment of alcohol
dependence of adolescents
HELMUT NIEDERHOFER & WOLFGANG STAFFEN
Drug and Alcohol Review (September 2003), 22, 295 – 297
Abstract
About 50% of alcoholic patients relapse within 3 months of treatment. Previous studies have suggested that disulfiram may help to
prevent such relapse. The aim of our study was @@to assess the efficacy and safety of long-term disulfiram treatment in alcohol
dependence of adolescents.@@
In this @@double-blind, placebo-controlled study@@ we recruited @@N = 26 adolescents@@, aged @@16 – 19 years@@, with chronic or episodic alcohol dependence.
Patients were allocated treatment randomly with disulfiram (200 mg daily) or placebo for 90 days.
Patients were @@assessed@@ on the day @@treatment started@@ and on @@days 30 and 90@@ by
#interview,
#self-report,
#questionnaire and
#laboratory screening.
Patients were classified as
#abstinent,
#relapsing or
#non-attending.
Time to first treatment failure (relapse or non-attendance) was the primary outcome measure.
The disulfiram (n =13) and placebo (n = 13) groups were well matched in terms of baseline demographic and alcohol-related variables.
@@Results:@@
Thirteen disulfiram-treated and 13 placebo-treated patients completed the treatment phase;
#seven (1 vs. 6) relapsed,
#five (3 vs. 2) refused to continue treatment,
#three (1 vs. 2) had concurrent illness and
#two (1 vs. 1) had adverse side effects.
At the end of treatment, seven disulfiram-treated and two placebotreated patients had been abstinent continuously (p= 0.0063).
Mean cumulative abstinence duration was significantly greater in the disulfiram group than in the placebo group [68.5 (SD 37.5) vs. 29.7 (19.0) days; p =0.012]. Apart from occasional diarrhoea, there was no difference in side effects between groups. In some cases, disulfiram may be an effective and well-tolerated pharmacological adjunct to psychosocial and behavioural treatment programmes for treatment of adolescent alcohol-dependent patients.
DB: Very small numbers - power calcs? Confidence intervals? Effect sizes?

European Child & Adolescent Psychiatry
12:144–148 (2003)
Acamprosate and its efficacy in treating
alcohol dependent adolescents
Abstract
''Background''
About 50% of adult alcoholic patients relapse within 3 months of treatment. Previous studies have suggested that acamprosate may help to prevent such relapse.
@@"Acamprosate (calcium acetylhomotaurinate) has a chemical structure similar to that of amino acid neuromediators such as taurine and GABA [10].Acamprosate has been reported to stimulate inhibitory GABA transmission and to antagonise excitatory amino acids, particularly glutamate [11, 12]. Restoration of the inhibition/excitation balance might be the biochemical basis
of acamprosate’s clinical effects; acamprosate reduces voluntary alcohol intake in alcohol-dependent rats in a dose-dependent way [10–13].Acamprosate does not enhance alcohol toxicity [14], has no abuse potential itself, and has no hypnotic, anxiolytic, or muscle-relaxant properties [15]. Acamprosate is absorbed through the gastrointestinal tract and a steady state is reached after 7 days; the drug is not metabolised and the kidney is probably the only route of excretion. Pharmacokinetic variables are not modified by hepatic dysfunction (LIPHA unpublished data). Several clinical trials [16–19] of acamprosate (using only adults) have been promising. However, most reported only 3 months’ treatment and used endpoints other than continuous (e. g. glutamyl transpeptidase, reduction in alcoholic drinks),but there are also papers which deny significant effects of acamprosate [20–22].We therefore undertook a double-blind, placebo-controlled trial of 90 days’ treatment with acamprosate."@@
The aim of our study was to assess the efficacy and safety of long-term acamprosate treatment in alcohol dependence of adolescents.
''Methods''
In this, double-blind, placebo-controlled study, we recruited 26 patients, aged 16–19 years,with chronic or episodic alcohol dependence.
@@"Eligible patients were those who presented to our hospital that treats inpatients with alcohol dependence of chronic or episodic type (DSM-IV criteria).Patients had to be aged 16–19 years; to have been abstinent for at least 5 days before the study; to have a γGT value of at least twice the upper limit of the normal range or a mean corpuscular volume of 93 fl or more, or both; and they as well as their parents gave written informed consent.We used the CAGE questionnaire [24] – four clinical interview questions on cutting down, annoyance by criticism, guilty feelings, and eye-openers and the Michigan
alcoholism screening test to assess the severity of patients’ alcoholism."@@
Patients were randomly allocated treatment with acamprosate (1332 mg daily) or placebo for 90 days. Patients were assessed on the day treatment started and on days 30, and 90 by interview, self report, questionnaire, and laboratory screening.
''Findings''
13 acamprosate-treated and 13 placebotreated patients completed the treatment phase: of those withdrawn, 11 (1 vs 6) relapsed, 5 (3 vs 2) refused to continue treatment, 3 (1 vs 2) had concurrent illness, and 2 (1 vs 1) had adverse side-effects. At the end of treatment, 7 acamprosate treated and 2 placebotreated patients had been continuously abstinent (p= 0.0076).Mean cumulative abstinence duration was significantly greater in the acamprosate group than in the placebo group (79.8 [SD 37.5] vs 32.8 [19.0] days; p= 0.012).
''Interpretation''
Acamprosate is an effective and well-tolerated pharmacological adjunct to psychosocial treatment programmes.
Note: Niederhofer quotes research on NALTREXONE as an alternative possible anti-craving medication - but no research on adolescent patients completed and his acamprosate research appeared on the surface to get higher success even though he didn't use "motivation" as an aceptance criterion:
"Volpicelli and colleagues’ [2] study led to the registration
of naltrexone, an opioid antagonist, for treatment
of alcohol dependence in the USA. In their 12-
week placebo-controlled, double-blind study, there was
a significant difference in rates of relapse (defined as
clinically significant) drinking between naltrexone and
placebo groups of adult patients; the relapse rate with
naltrexone was 23%.By comparison, in our study on assessment
day 90 (the nearest assessment to Volpicelli
and colleagues’ 12 weeks), the relapse rate with acamprosate
was 19%. We believe acamprosate compares
favourably with naltrexone, because we had a less selective
study sample; motivation was not an inclusion criterion
as it was in Volpicelli and collegues’ study."

COMPARISON OF CYANAMIDE AND PLACEBO IN THE TREATMENT OF ALCOHOL
DEPENDENCE OF ADOLESCENTS
Alcohol & Alcoholism Vol. 38, No. 1, pp. 50–53, 2003
DB: - Small numbers, limited power, kids needed high level supervision and note hepatotoxicity og Cyanamide - unlkiely to be a practical choice... 3Star only
''Cyanamide:''
"Cyanamide is an aldehyde dehydrogenase (ALDH) inhibitor
used as a pharmacological adjunct in the aversive treatment of
chronic alcoholism. Its elimination half-life and total plasma
clearance values range from 42.2 to 61.3 min and its oral
bioavailability is 70 at a 1.0 mg/kg dose (Colom et al., 1999).
Cyanamide blocks ethanol metabolism by inhibition of both
the low- and high-Km forms of ALDH (Loomis and Brian,
1983a,b; Cederbaum and Dicker, 1985) in a pH-dependent
manner [at pH < 7.5 formation of an irreversible form, at
pH > 8.5 formation of a reversible form (DeMaster et al., 1998)].
As a result of this inhibition an increase is induced in acetaldehyde
concentrations in blood and liver. This is responsible
for the alcohol deterrent activity of cyanamide, because it
induces a severe reaction (the toxic acetaldehyde syndrome)
characterized by tachycardia, hypotension, flushing and
dyspnea (Brien et al., 1978, 1979)."
NB Colin Brewer (Alcohol & Alcoholism Vol. 38, No. 5, pp. 442–445, 2003) criticises choice of Cyanamide and the lack of reference to Disulfiram as an alternative:
"However, despite the obvious similarities in mode of action between cyanamide
and disulfiram, I am puzzled that the above authors made
absolutely no mention of the use of disulfiram in treatment.
Ironically, their only reference to disulfiram is to a paper
which compares its hepatotoxicity with that of cyanamide. Yet
the literature strongly suggests that, whereas cyanamide causes
histological changes in many patients, disulfiram causes only
rare and idiosyncratic hepatotoxicity, which is commoner in
women and is probably due to nickel sensitivity from costume
jewellery (Brewer and Hardt, 1999).... ...Finally, it would be interesting to know @@why Niederhofer
et al. (2003) chose a drug which needs to be given three times
daily when they could have used disulfiram, which only needs
to be given once daily or even thrice weekly.@@ Nevertheless, I
congratulate them on a well-planned study in a group of patients
who are often resistant to treatment."
Abstract:
Abstract — Aims: About 50% of alcoholic patients relapse within 3 months of treatment. Previous studies have suggested that cyanamide
may help to prevent such relapse. The aim of our study was to assess the efficacy and safety of long-term cyanamide treatment in
alcohol dependence of adolescents. Methods: In this, double-blind, placebo-controlled study, we recruited 26 patients, aged 16–19
years, with chronic (frequent and regular) or episodic (frequent, but irregular) alcohol dependence. Patients were randomly allocated
treatment with cyanamide (200 mg daily) or a placebo for 90 days. Patients were assessed on the day the treatment was started, and
on days 30 and 90, by interview, self-report, questionnaire and laboratory screening. Patients were classified as abstinent, relapsing or
non-attending. Time to first treatment failure (relapse or non-attendance) was the primary outcome measure. Results: The cyanamide
(n = 13) and placebo (n = 13) groups were well matched in terms of baseline demographic and alcohol-related variables. Mean cumulative
abstinence duration was significantly greater in the cyanamide group than in the placebo group. Apart from occasional diarrhoea, there
was no difference in side effects between groups.
@@Conclusions:
Cyanamide seems to be an effective and well tolerated pharmacological adjunct to psychosocial and behavioural treatment programmes for the treatment of some adolescent alcohol-dependent patients. @@Because of reported hepatotoxic, haematological and dermatological side effects, patients should be observed continuously by experienced clinicians.@@ Further studies are necessary to prove the efficacy of cyanamide in adolescents.

Trial reported in ''letter to the editor'':
Alcohol Clin Exp Res, Vol 27, No 1, 2003: p 136
We used the Michigan alcoholism screening test (Selzer,
1971) to assess the severity of alcoholism of 26 inpatients
without serious coexisting diseases or receiving drugs acting
on the central nervous system (after written informed consent).
They were 16–19 years of age, abstinent for at least
5 days before the study, with alcohol dependence of chronic
or episodic type (DSM-IV criteria), whose yGT value was
at least twice the upper limit of the normal range, and
whose mean corpuscular volume was 93 fl or more. They
were randomly assigned to tianeptine or placebo, while
psychosocial treatment (psychotherapy three times a week,
physiotherapy and ergotherapy) was started. Patients received
37.5 mg tianeptine or Placebo daily. They were
classified as abstinent or relapsed according to his or her
self-report 30 and 90 days after the first administration of
tianeptine. We checked the red and white blood count,
serum concentrations of sodium, potassium, chloride, calcium,
phosphate, blood urea nitrogen, creatinine, uric acid,
fasting blood glucose, alkaline phosphatase, total bilirubin,
cholesterol, triglycerides, and albumin. There were no initial
differences between tianeptine (n 13) and placebo
groups (n 13) in quantity and frequency of drinking, and
Hamilton depression scores.
Although our sample of adolescents was relatively small
and the time of abstinence was relatively short, our data
show, that the proportion of patients who remained abstinent
was higher in the tianeptine group than in the placebo
group throughout the 90 days of treatment. On day 90, 2 of
the placebo-treated patients, compared with 5 tianeptinetreated
patients, had been continuously abstinent (Mantel-
Cox test; p 0.0063). Mean cumulative abstinence duration
was also significantly greater in the tianeptine group
than in the placebo group (69.2 [SD 38.3] vs 31.4 [17.9]
days; p 0.012). There were no remarkable side effects in
both groups. Tianeptine had no effect on hematology or
serum biochemistry.

!From the Independent Scientific Committee on Drugs
(Prof David Nutt's Group)
http://www.drugscience.org.uk/nitrousadvice.html
!Nitrous Oxide: harm reduction advice
Drug Information - Nitrous Oxide/ Laughing Gas / N2O
!What is Nitrous oxide?
Nitrous oxide, (N20) is a gas with pain-relieving properties. It has been used as a recreational drug for over 200 years; about as long as it has been used in medicine. Nitrous oxide mixed with oxygen is the ‘gas and air’ given to women in labour, and is used in dentistry to relieve pain and anxiety. It has become widely and easily available for recreational use because it can be legally sold for the purpose of making whipped cream quickly.
!Patterns of Use
Since the ‘laughing gas parties’ held by the upper classes in the Georgian era, nitrous oxide is a drug most associated with occasional social use. It is popular at house parties and music festivals, where balloons filled with the gas may cost around £1.50. Whilst some people do take it alone (sometimes to enhance sexual pleasure), few make it a regular part of their lives. However, very occasionally, people become dependent and take it persistently.
!Appearance and effects
Nitrous oxide itself is a colourless gas that is slightly sweet-smelling and tasting. Recreational users normally get it from whipped-cream chargers, sometimes called ‘whippits’, which are single-use, finger-length steel cartridges containing 8g of highly pressurised nitrous oxide. Whippits are usually discharged into a balloon with a kind of whipped cream dispenser or a smaller widget called a ‘cracker’. Nitrous oxide is also found in supermarket cans of whipped cream. Other sources include full sized gas cylinders, intended for medical or industrial use.
When someone inhales nitrous oxide, the gas rapidly dissolves into the bloodstream, and hits the brain within seconds. Effects vary between people and are rarely quite the same twice, but a rush of dizziness and euphoria is normal, and people often burst out laughing. Sound is oddly distorted, voices and music often turning into a throbbing roar like a helicopter.
Nitrous oxide is a ‘dissociative’ drug, so the user might feel like they are becoming apart from the situation they were in, or even their own body, and sounds and sights can seem to fade into the distance. Hallucinations are possible, from simple moving bright dots to complete detailed dreamscapes, although most users do not experience complex hallucinations. Coordination is affected and users may fall over if they are not sitting or lying down. The experience ends almost as swiftly as it began, with the peak lasting just seconds and the user back to normal within about 2 minutes. Sometimes, people take many ‘hits’ of nitrous oxide over a few hours.
Aside from these mental effects, when inhaled recreationally in the usual (and safest) way, from a balloon, the gas in the lungs displaces air, temporarily preventing a normal amount of oxygen getting into the blood. This may cause the heart to beat faster, and limbs to feel tingly or heavy.
!Harms, and avoiding them
Nitrous oxide use can cause harm and even death but most problems result from dangerous methods of use and not the drug itself. If the user is in good health, understands the risks, and avoids dangerous methods, nitrous oxide is one of the least risky drugs. It is very much less dangerous than other commonly used inhalants such as household solvents (e.g. butane and toluene). The foremost risk is of brain damage and death by asphyxiation. Secondly, addiction is a serious but very rare outcome of nitrous oxide use. These, and other lesser risks are described in detail below, with advice on how they can be avoided.
The greatest risks from inhaling this drug come from using it in a way that causes uncontrolled and prolonged oxygen deprivation. Inhaling nitrous oxide in a dangerous way may not cause any warning symptoms until the user suffers sudden unconsciousness, then brain damage, followed by death within minutes. This risk requires some explanation. With knowledge, this risk can be easily avoided.
If you hold your breath, your body is deprived of the oxygen it needs from the air. However, holding your breath is not very dangerous, because within seconds, the body’s automatic alarm system kicks in, making you feel uncomfortable, and before too long, it forces you to breathe. Surprisingly, this life-preserving system doesn’t work by directly monitoring falling oxygen levels, but instead detects the simultaneously rising levels of carbon dioxide which your body would normally breathe out.
If you have your head in a bag of nitrous oxide, or even a bag of nitrous oxide mixed with air, you are still able to breathe out carbon dioxide freely, so your body is tricked into thinking that it is breathing normally. So you may feel no discomfort, and be enjoying the drug effects, right up to the moment when you black out. Unconscious with a bag over your head, it takes just a couple of minutes for brain cells to begin dying, and another couple of minutes before you are dead. Because the gas reduces anxiety and coordination even before causing unconsciousness, it may be impossible to escape from such a situation even if you realise your mistake.
Several people have died in this exact way, and also from opening tanks of nitrous oxide in confined spaces such as cars, or strapping on medical gas masks attached to cylinders of pure N2O. It is vital to note that a person can suffocate like this even if they have access to some air; for example if they deliberately left the bag loose around their neck, or left their car window slightly open. Getting some oxygen, but not enough, will have the same fatal effect, although perhaps more gradually. Pressurised gas from whippits and gas cylinders takes up much more space than might be expected when it is released; pushing air out of gaps where the user might have thought it would come in.
These risks of death or brain damage by asphyxiation are very easy to avoid. What the potentially fatal methods have in common is that if the user passes out, they will continue to inhale the gas or a low-oxygen gas and air mixture instead of pure air, leading eventually to death. With the common balloon method, (condoms are usable too) oxygen levels in the body still drop, but if the user gets too close to passing out, they will be unable to hold the balloon to their lips, and will automatically breathe air again. With this method, delivery of the gas is not automatic and continual so asphyxiation is virtually impossible. Even with this method, users often get a headache, which may be from not taking enough breaths of air, or from not leaving several minutes between balloons for recovery of oxygen levels, as well as from the effects of the gas on blood vessels in the head.
Gas at pressure is dangerous, so care must be taken when filling balloons. Faulty dispensers (especially cheap ‘crackers’), or incorrect use, could cause explosions. When gas is released from pressurised containers, the gas and the metal of the container briefly becomes intensely cold (-40°C). People have given themselves frostbite of the lips, mouth and even vocal chords through inhaling laughing gas directly from the whippit ‘cracker’, or the nozzle of gas cylinders, and further serious damage could be done to the lungs if the gas came out at high pressure. Dispensing several whippits consecutively with one cracker can cause cold burns to hands.
There is a risk of falling when taking nitrous oxide whilst standing or dancing. It is safest to get comfortable on a sofa or bed.
It is possible that some mental health problems might be worsened, or relapses triggered, by the trippy effects of nitrous oxide, although there is no specific evidence of this.
People with heart conditions or abnormal blood pressure may be at higher risk as the drop in oxygen levels caused by inhaling nitrous oxide raises the heart rate and can cause arrhythmias (skipped beats), which are usually not problematic, but could cause heart attacks and similar emergencies in susceptible people. For similar reasons, it would be inadvisable to mix laughing gas with other drugs, especially stimulants, as effects on blood pressure and heart rate could be unpredictable.
There is a risk of contamination of the gas with harmful substances. Tanks of nitrous oxide intended for use in cars are usually contaminated with sulphur dioxide and other toxins. It has been noticed that some brands of whipped-cream chargers leave an oily residue inside the dispenser, suggesting that they contain some impurities. No specific evidence of harm from this exists, and many people have used the chargers with no health problems, but there can be no guarantees of safety when using this product in a way not intended by the manufacturers.
!Addiction and harms from long-term use
Because the effects of nitrous oxide are pleasurable but short-lasting, people are often tempted to take it repeatedly over a short space of time. Very occasionally people become psychologically addicted to nitrous oxide and find it difficult to resist taking it every day. People with mental health issues may be at additional risk of addictive behaviours.
Nitrous oxide is not particularly addictive compared to other drugs, and addictions usually require a combination of a psychological vulnerability, (such as low moods or worries that the drug briefly relieves), and easy access to the gas. Stressed dentists and anaesthetists who work with the substance always at hand have become addicted. Although addiction is unlikely, if it occurs it can be very harmful.
Aside from the disruption that maintaining a drug addiction causes to lives, it has been found that nitrous oxide can be physically and mentally damaging when taken many times each day for long periods as it gradually inactivates the vitamin B12 reserves in the body. Individuals who inhaled large amounts of nitrous oxide daily for long periods have suffered nerve and brain damage because vitamin B12 is essential for the maintenance of a healthy nervous system. The symptoms of such damage vary, and have included severe weakness of the arms and legs in some, and in a handful of cases, episodes of mental illness. Treatment with high doses of B12 is effective, but some damage can be irreversible. It is likely that less severe vitamin B12 deficiencies caused by nitrous oxide overuse go undiagnosed, but cause milder symptoms, such as depression, forgetfulness and tiredness. If you are struggling to control your use of any substance you should see your doctor.
!Law
It is illegal to sell nitrous oxide to under-18s, and selling it to anyone you suspect may use it for the purposes of inhalation is illegal under the Medicines Act. However, it is widely and legally sold as a means to whip cream. Possession of whippits is legal, but if the police found you with large amounts of whippits without a cream-preparation-based explanation, you could be charged with intending to supply it for inhalation.

Noel, Pamela E. (2006) 'The Impact of Therapeutic Case Management on Participation in Adolescent Substance Abuse Treatment',
The American Journal of Drug and Alcohol Abuse, 32:3, 311 - 327
from abstract:
"Ninety adolescent women enrolled in substance abuse treatment were randomly assigned to receive or to not receive case management. Treatment fidelity was measured using the Case Management Quality Inventory. Cox regression analyses revealed that higher fidelity of case management implementation predicted a decreased risk of dropping out of the substance abuse treatment program (RR = - 11.21, p < 0.02). Higher proportions of total case management time spent on case management core functions predicted a decreased risk of dropping out of treatment (RR = 4.32, p < 0.03).
''Case Management definitions'':
"the following core elements are generally present:
#assessment of the need for health and social services;
#planning and coordination;
#monitoring to ensure that services are received and are satisfactory; and
#advocacy on behalf of the client.
More comprehensive case management programs also provide counseling/psychotherapy, transportation, and home visitation."
Hypotheses
#participants ''who receive case management'' stay in treatment longer than participants who do not receive case management;
#higher ''fidelity'' of case management implementation predicts a lower probability of dropping out of substance abuse treatment;
#higher ''intensity'' of case management service predicts a lower probability of dropping out of treatment.
90 adolescent females (mean age 16)
Assenting to group SUD programme, mixed ethnicities, @@NB some question about the severity of the "SUD" they were receiving Rx for... "Most participants (52%) had used at least one substance to get high in the 3 months prior assessments"...@@ not clear if they had DSM IV SUD diagnoses or not...
RAndomly assigned to CASE MANGAMENT of NOT - no stat diff between groups
Interventions:
"the ''case manager''’s relationship to the client was primarily therapeutic, and the case management functions (e.g., assessment, service planning, linking to resources, coordination, advocacy etc.) were undertaken as a part of the therapeutic intervention. Cognitive-behavioral therapeutic techniques were used to accomplish the goals of therapy of which the primary goal was to prevent, reduce, or ameliorate the effects of alcohol and other drug use in the client’s life."
Attempted ethnicity matching with ase managers and clients
''Training of Case managers:''
"Case managers were master’s level social workers with at least one year of prior work experience in the field. Case managers underwent a full week of intensive training on the case management model, record keeping procedures, and the overall research protocol prior to implementing the program. In addition, case managers participated in workshops on a variety of topics geared towards their professional development. Case managers received both individual and group supervision on a regular basis."
Outcome measures:
Personal Experince Inventroy (incl self report drug/alc use)
Child Depression Inventroy, etc
Fidelity to CAse Management Model - not on a validated scale (as far as I can see) - 100 point scale
Survival Analyses (variable is "time until an event happens"...)
(a) the survival distribution for the case-managed and noncase-managed groups was significantly different ( p < 0.05). The median survival time for noncase-managed participants was 8 sessions, and the median for the case-managed group was 12 sessions.
(b) Only fidelity of case management implementation, and proportion of total case management time spent on case management core functions (i.e., outreach, assessment, service planning and resource identification, linking clients to services, service coordination, monitoring service delivery, and advocacy) had a statistically significant impact on attrition. With each unit increase in the case management fidelity score, the risk for dropping out of substance abuse treatment decreased by 21% ( p = 0.02). In other words, ''higher case management fidelity scores predicted lower risk fordropping out of substance abuse treatment.'' With each unit increase in the proportion of total case management time spent performing case management
core functions, the risk of dropping out of treatment decreased by 32% ( p = 0.03). In other words, ''higher proportions of total case management time spent on case management core functions predicted lower risk for dropping out of treatment''.
Limitations:
#@@But did staying in Rx have any effet on Rx OUTCOMES for the clients????@@
#"The current study did not measure implementation of the control group. By not measuring implementation of the control group, the author of the current study may not have captured the full impact of case management on attrition.
#Small numbers - difficult to generalise but intersting hypoothesis - gets 3 stars

Commentary on [[Marsch et al 2005]]
"The Food and Drug
Administration is currently considering
a depot preparation of naltrexone
that is effective with monthly injections.
If this treatment becomes
available, it will provide an effective
option for maintaining longterm
abstinence from opiates among
opiate-abusing adolescents"

From [[Dawes and Johnson 2004]]:
5-HT3 antagonists: ondansetron. The 5-HT3 receptor has
been implicated in the molecular mechanisms regulating
alcohol consumption and mediating the actions of alcohol,
alcohol reinforcement and ondansetron treatment response.
Behavioural pharmacological studies have shown that the
rewarding effects of alcohol are modulated by ethanol-induced
activation of mesocorticolimbic DA receptors interacting with
5-HT3 receptors in the midbrain and cortex (Johnson and
Cowen, 1993; Barnes and Sharp, 1999; McBride et al., 2004).
Ondansetron has been shown in studies from two different
research groups to decrease alcohol consumption (Johnson
et al., 2000b; Kranzler et al., 2003) in adults with early-onset
alcohol dependence. Johnson et al. (2000b) showed in a sample
of 321 alcohol-dependent individuals that ondansetron, at 1, 4
and 16 g/kg twice per day, was superior to placebo in decreasing
drinks per day and drinks per drinking day. The 4 g/kg
b.i.d. dose, compared with placebo, also significantly increased
percentage of days abstinent and total days abstinent per study
week (Johnson et al., 2000b). In a prospective, open-label study
of ondansetron in early- versus late-onset alcohol-dependent
adults (n = 40; 20 early-onset alcohol-dependent adults, EOA;
20 late-onset alcohol-dependent adults, LOA), together with
weekly relapse prevention therapy, EOA reported significantly
greater decreases in drinks per day and drinks per drinking day,
and reductions in alcohol-related problems, compared with
LOA (Kranzler et al., 2003). Results from a recent open-label
study of adolescents with alcohol use disorders (n = 12) who
received 4 microg/kg b.i.d. also showed significant within-group
decreases in self-reported alcohol consumption (Dawes et al.,
unpublished observations). Side-effects were mild....

Twelve-step and cognitive-behavioral treatment for substance abuse: A comparison of treatment effectiveness.
By Ouimette, Paige Crosby; Finney, John W.; Moos, Rudolf H.
Journal of Consulting and Clinical Psychology. 1997 Apr Vol 65(2) 230-240
NB not for adoelscents
Abstract
The comparative effectiveness of 12-step and cognitive-behavioral (C-B) models of substance abuse treatment was examined among 3,018 patients from 15 programs at the US Department of Veterans Affairs Medical Centers. Across program types, participants showed significant improvements in functioning from treatment admission to a 1-year follow-up. Although 12-step patients were somewhat more likely to be abstinent at the 1-year follow-up, 12-step, C-B, and combined 12-Step-C-B treatment programs were equally effective in reducing substance use and improving most other areas of functioning. The finding of equal effectiveness was consistency over several treatment subgroups: Patients attending the "purest" 12-step and C-B treatment programs, and patients who had received the "full dose" of treatment. Also, patients with only substance abuse diagnoses, those with concomitant psychiatric diagnoses, and patients who were mandated to treatment showed similar improvement at the 1-year follow-up, regardless of type of treatment received. These data provide important new evidence supporting the effectiveness of 12-step treatment. (PsycINFO Database Record (c) 2007 APA, all rights reserved)

Peggy L. Peterson, John S. Baer, Elizabeth A. Wells, Joshua A. Ginzler, and Sharon B. Garrett (2006)
!Short-Term Effects of a Brief Motivational Intervention to Reduce Alcohol and Drug Risk Among Homeless Adolescents
Psychology of Addictive Behaviors 2006, Vol. 20, No. 3, 254-264
ditto [[Baer et al 2007]] - an earlier report on same study -
Conceptualises Brief Motivational Enhancement as a tool for outreach engagement .
Guided by TRANSTHEORETICAL MODEL (Stages of Change - Prochaska and DiClemente) … & THEORY of REASONED ACTION (Morrison et al 2002)
Single session with FEEDBACK
285 (13- 19 yrs olds) recruited actively and passively from outreach projects, word of mouth, criteria for at risk status re. SUD.
NB financial incentives: Up to $90 cash payments for attendances.
Most subjects at "pre-contemplation" stage of change re "abstinence" (77.6% and 84.5% for drugs and alcohol) but for "reduce use" more were in contemplation and preparation stages (only 50.3% and 52.9% in pre-contemplation for alc and drugs)
Randomised (urn) , partial repeated measures design
3 groups: -
(a) active Rx, (ME)
(b) Assessment only (AO) but WITH NO FEEDBACK) , and
(c) assessment at follow-up only (AFO). AFO got initial brief screen and gave contact details, then were randomised but not given baseline assesst until //follow up// at 1 m, and 3 m.
Urine drug screen at 3 m. for all.
Multiple measures using valid instruments and checks on validity (recorded sessions and supervision - tho recordings low quality and not resourced to do formal checks on model fidelity.
Retention rate of 80% at 3 m. follow up = "quite good"
"No evidence of effectiveness on drug use (alcohol or CBS) altho Rx group reported reduced other illicit drug use (at 1/12 only).
Theorise that this is a fucntion of supporting 'natural change' processes and therefore worth further pursuing.
Variability in treatment response could be predicted by therapist ratings of ENAGEMENT in Rx. (Note: [[McCambridge and Strang 2004]] noted
that //practitioner ratings// of discussions of change predicted outcomes for marijuana use in a nontreatment sample.)
On the other hand - not necesarily the case that homeless SUD adols need/would benefit from more intensive treatments - poor engagment in these too... potential probs relating to the extent to which the trial intervention was SEPARATE from existing street agencies, as opposed to integrated."

Studies funded by Pharmaceutical companies

!Author:
D. Polsky, H. A. Glick, J. Yang, G. A. Subramaniam, S. A. Poole and G. E. Woody
!Year:
2010
!Title:
Cost-effectiveness of extended buprenorphine-naloxone treatment for opioid-dependent youth: data from a randomized trial
Journal: Addiction
Volume: 105
Issue: 9
Pages: 1616-24
!Abstract:
!AIMS:
The objective is to estimate cost, net social cost and cost-effectiveness in a clinical trial of extended buprenorphine-naloxone (BUP) treatment versus brief detoxification treatment in opioid-dependent youth.
!DESIGN:
Economic evaluation of a clinical trial conducted at six community out-patient treatment programs from July 2003 to December 2006, who were randomized to 12 weeks of BUP or a 14-day taper (DETOX). BUP patients were prescribed up to 24 mg per day for 9 weeks and then tapered to zero at the end of week 12. DETOX patients were prescribed up to 14 mg per day and then tapered to zero on day 14. All were offered twice-weekly drug counseling.
!PARTICIPANTS:
152 patients aged 15-21 years.
!MEASUREMENTS:
Data were collected prospectively during the 12-week treatment and at follow-up interviews at months 6, 9 and 12.
!FINDINGS:
The 12-week out-patient study treatment cost was $1514 (P < 0.001) higher for BUP relative to DETOX. One-year total direct medical cost was only $83 higher for BUP (P = 0.97). The cost-effectiveness ratio of BUP relative to DETOX was $1376 in terms of 1-year direct medical cost per quality-adjusted life year (QALY) and $25,049 in terms of out-patient treatment program cost per QALY. The acceptability curve suggests that the cost-effectiveness ratio of BUP relative to DETOX has an 86% chance of being accepted as cost-effective for a threshold of $100,000 per QALY.
!CONCLUSIONS:
Extended BUP treatment relative to brief detoxification is cost effective in the US health-care system for the outpatient treatment of opioid-dependent youth.

<<tag Prevention>>

Research into the "how" of why a therapy works - i.e. the focus in sessions, the therapeutic alliance, the deployment of specific techniques as opposed to a reified "thing-called-XYZ-therapy"...

Multisystemic therapy: A treatment for violent substance-abusing and substance-dependent juvenile offenders
Jeff Randall*, Phillippe B. Cunningham
Addictive Behaviors 28 (2003) 1731–1739
Good [[Review]] of MST for violent and SU adolescents
includes description of the addition of [[ACRA]] to [[MST]] to boost SUD effectiveness:
CRA has strong empirical support, and it is theoretically compatible with MST. Key
components of CRA are the following: (a) consistent tracking of substance use through
frequent urine screens, with vouchers used as rewards for clean drug screens; (b) functional
analyses of drug use to identify triggers for drug use; (c) self management plans consisting of
cognitive behavioral interventions that focus on addressing the emotional, behavioral, and
environmental triggers to drug use for the individual; and (d) development of drug avoidance
skills. In contrast to MST, which focuses primarily on broader environmental risk and
protective factors, CRA focuses very specifically on substance use. Pilot testing of an
integration of MST and CRA was conducted in a randomized MST trial that evaluated the
MST as an alternative to emergency psychiatric hospitalization (Henggeler, Rowland, et al.,
1997, 1999; Henggeler et al., 2003) and in a quasi-experimental neighborhood-level
intervention project (Randall, Swenson, & Henggeler, 1999)

Jeff Randall, Scott W. Henggeler, Phillippe B. Cunningham, Melisa D. Rowland, and Cynthia C. Swenson (2001) //Adapting Multisystemic Therapy to Treat Adolescent
Substance Abuse More Effectively// Cognitive and Behavioral Practice 8, 359-366, 2001
!Abstract
The article illustrates an adaptation of multisystemic therapy (MST) coupled with community reinforcement plus vouchers approach
(CRA ) to treat adolescent substance abuse and dependency. Key features of CRA enable the MST therapist and adolescent caregiver to
mare specifically detect and address adolescent substance use. These features include frequent random urine screens to detect drug use,
functional analyses to identify triggers for drug use, self-management plans to address identified triggers, and development of drug
avoidance skills. To highlight the integration of MST and CRA in treating substance abusing or dependent adolescents, a case example
is provided. Prior to the case example, an overview of clinical and program features of MST and substance-related outcomes is presented.

Paula D. Riggs (2003) Treating Adolescents for Substance Abuse and Comorbid Psychiatric Disorders Sci Pract Perspect. 2003 August; 2(1): 18–29.
!Abstract
Recent research has identified a cluster of standardized approaches that effectively treat adolescents
with substance abuse disorders. Many of these approaches share elements that may
be adopted to improve outcomes in substance treatment programs. In adolescents, treatment
goals should be informed by a comprehensive assessment that includes the adolescent
patient’s developmental history and evaluation of psychiatric comorbidity. Treatment for
behavioral, psychosocial, and psychiatric problems should be integrated with substance
abuse interventions. The author describes practical clinical guidelines, grounded in current
research, for providing integrated treatment services. Special emphasis is given to strategies
for integrating the treatment of comorbid psychiatric disorders with substance use disorders
in adolescents.
!paper
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851046/pdf/spp-02-1-18.pdf

A Randomized Controlled Trial of Fluoxetine and Cognitive Behavioral Therapy in Adolescents With Major Depression, Behavior Problems, and Substance Use Disorders
Paula D. Riggs, MD; Susan K. Mikulich-Gilbertson, PhD; Robert D. Davies, MD;
Michelle Lohman, RN; Constance Klein, MSW; Shannon K. Stover, BA
Arch Pediatr Adolesc Med. 2007;161(11):1026-1034
!''Abstract'' (DB notes in @@highlight@@)
''Objective:''
To evaluate the effect of fluoxetine hydrochloride vs placebo on major depressive disorder, substance use disorder (SUD), and conduct disorder(CD)in adolescents receiving cognitive behavioral therapy (CBT) for SUD.
''Design:''
Randomized controlled trial. @@randomised by a small block randomisation - researchers/clinicians blinded thereafter@@
''Setting:''
A single-site study conducted between May 2001 and August 2004.
''Participants:''
126 adolescents aged 13 to 19 years recruited from the community and meeting Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnostic criteria for current major depressive disorder, lifetime CD, and at least 1 nontobacco SUD.
''Interventions:''
Sixteen weeks of fluoxetine hydrochloride, 20 mg/d, or placebo, with CBT. @@weekly medcation checks (pill count, SE montioring, etc) - CBT session after that. manualised CBT focussed on SUD (a la [[Waldron et al 2001]])@@
''Main Outcome Measures:''
#For depression, __Childhood Depression Rating Scale–Revised__ and __Clinical Global Impression Improvement__;
#for SUD, self-reported (''TLFB'') nontobacco substance use and weekly ''urine substance use screen'' results in the past 30 days; and
#for CD, self-reported symptoms in the past 30 days.
@@all analyses were I.T.T.@@
''Results:''
@@328 initial screenings, 143 consented, 126 randomised (loss via various routes - incarceration, pregnancy, etc..) NO stat differences between the 2 groups of 63 each (SSR and Placebo). Level of Depression: mean baseline CDRS-R raw score was 56.84
(13.42), which translates to a normed t score of 73.38 (8.09) (standardized to a mean of 50 [10]), indicating ''moderate to moderately severe depression'' consistent with the mean CGI-S score rating of 4.76 (0.84). NB. 20.6% of the sample were mandated to Rx by COURT - but this group similar to rest of group and equally distributed acrss both groups... the rates of Rx completion/no. of sessions each were not staistically differnt... the treatment response and remission rate was HIGHER THAN EXPECTED //across BOTH// groups ... "high levels of treatment response, based on the CGI-I in the fluoxetine-CBT (84.1%) and placebo-CBT groups (77.8%), but the difference between groups was not statistically significant. The estimated risk ratio for fluoxetine responders relative to placebo responders based on the CGI-I was 1.08 (95% confidence interval [CI], 0.91-1.28)"....triggering some post-hoc analyses @@
#Fluoxetine combined with CBT had greater efficacy than did placebo and CBT according to changes on the Childhood Depression Rating Scale–Revised (effect size, 0.78) but not on the Clinical Global Impression Improvement treatment response (76% and 67%, respectively; relative risk, 1.08).
#There was an overall decrease in self-reported substance use (4.31 days; 95% confidence interval, 2.12-6.50) and CD symptoms (relative risk, 1.20; 95% confidence interval, 0.82-1.59), but neither difference between groups was statistically significant.
#@@The proportion of substance-free weekly urine screen results was higher in the placebo-CBT group than in the fluoxetine-CBT group (mean difference, 2.10; 95% confidence interval, 0.37-4.15).@@
''Conclusions:''
Fluoxetine and CBT had greater efficacy than did placebo and CBT on one but not both depression measures and was not associated with greater decline in self-reported substance use or CD symptoms. The CBT may have contributed to higher-than-expected treatment response and mixed efficacy findings, despite its focus on SUD.
@@In conclusion, the results of this study indicate that fluoxetine combined with CBT may have similar safety and efficacy for depression in adolescents with active SUD to that reported for depressed adolescents without SUD.
However, the treatment was not associated with greater reduction in self-reported substance use and CD symptoms compared with placebo combined with CBT.
Our results also indicate that, in the context of CBT (substance treatment), co-occurring depression may improve or remit without antidepressant pharmacotherapy.
However, if depression does not appear to be improving early in the course of substance treatment, fluoxetine treatment should be considered, even if adolescents are not yet abstinent, with weekly monitoring of treatment adherence, substance use, adverse effects, and target symptom response.@@" - (latter highlighting is of the author's conclusions not DB)
!Funding etc
Financial Disclosure: Dr Davies is @@on the Speakers Bureau for Eli Lilly and Company@@ on the topic of the medication duloxetine hydrochloride (Cymbalta).
Funding/Support: This study was supported by grant NIDA DA13176 from the National Institute on Drug Abuse, National Institutes of Health.
Disclaimer: The sponsoring institution had no role in the design, implementation, data analysis, or preparation of this article.

Henk Rigter, Craig E. Henderson, Isidore Pelc, Peter Tossmann, Olivier Phan, Vincent Hendriks, Michael Schaub, Cindy L. Rowe. (2013) Multidimensional family therapy lowers the rate of cannabis dependence in adolescents: A randomised controlled trial in Western European outpatient settings. Drug and Alcohol Dependence. Volume 130, Issues 1–3, 1 June 2013, Pages 85–93
!Abstract
!!Background
Noticing a lack of evidence-based programmes for treating adolescents heavily using cannabis in Europe, government representatives from Belgium, France, Germany, The Netherlands, and Switzerland decided to have U.S.-developed multidimensional family therapy (MDFT) tested in their countries in a trans-national trial, called the International Need for Cannabis Treatment (INCANT) study.
!!Methods
INCANT was a 2 (treatment condition) × 5 (time) repeated measures intent-to-treat randomised effectiveness trial comparing MDFT to Individual Psychotherapy (IP). Data were gathered at baseline and 3, 6, 9 and 12 months thereafter. Study participants were recruited at outpatient secondary level addiction, youth, and forensic care clinics in Brussels, Berlin, Paris, The Hague, and Geneva. Participants were adolescents from 13 through 18 years of age with a recent cannabis use disorder. 85% were boys; 40% were of foreign descent. One-third had been arrested for a criminal offence in the past 3 months. Three primary outcomes were assessed: (1) treatment retention, (2) prevalence of cannabis use disorder and (3) 90-day frequency of cannabis consumption.
!!Results
Positive outcomes were found in both the MDFT and IP conditions. MDFT outperformed IP on the measures of treatment retention (p < 0.001) and prevalence of cannabis dependence (p = 0.015). MDFT reduced the number of cannabis consumption days more than IP in a subgroup of adolescents reporting more frequent cannabis use (p = 0.002).
!!Conclusions
Cannabis use disorder was responsive to treatment. MDFT exceeded IP in decreasing the prevalence of cannabis dependence. MDFT is applicable in Western European outpatient settings, and may show moderately greater benefits than IP in youth with more severe substance use.

The Efficacy of Structural Ecosystems Therapy With Drug-Abusing/
Dependent African American and Hispanic American Adolescents
190 African-American (n=77) and Hispanic (n=113) adolescents (78% boys), aged 12 - 17yrs, DSM IV diagnisis of SUD or Dependence)were randomized to:
#[[SET]] Structural Ecological Therapy, (n=57)
#FAM (Family process only condition)(n=67)
#CS (Control - Community supervision)(n=66)
Assessments were conducted at Baseline, 3, 6, 12, and 18 months postrandomization.
3 x 5 intent to treat stduy
Urn stratified randomisation
MAJOR STRENGTH IS THEIR ATTENTION TO ETHNICITY
There was statistically significant differential attrition from assessments among African Americans. African Americans in SET were more likely to complete the 18-month assessment (73%) than in FAM (52%) or CS (42%). No such diffs in the Hispanic group ...hence "dramatic differences between the number of sessions in SET and FAM among African Americans (19.48 in SET vs. 7.64 in FAM) and Hispanics (24.11 in SET vs. 17.66 in FAM)... adjusted for in post hoc analyses but did NOT CHANGE THE RESULTS (i.e. the results were not simply related to differnt DOSES of SET/FAM that diff ethnic groups got.)
''__Results__'':
''SET was significantly more efficacious than FAM and CS'' in reducing adolescent drug use. Complex calculations... "A statistically significant difference was observed on the linear slope component for the Ethnicity x FAM versus SET contrast (parameter estimate = 0.56), t(160) = 2.86,p = 0.004).
''//However, these improvements were limited to Hispanic adolescents//''.
The study demonstrates the importance of investigating changes in adolescent drug use as a result of treatment condition across more than 1 racial/ethnic group... It has NOT been proven efficacious with African Americans... this is in spite of the fact that SET ''was'' significantly efficacious "for African American participants ... in engaging adolescents and family members into treatment and in improving family functioning, //but these improvements did not change drug use.//".. the uathor postulates that this is possibly because African Americans are "less well represented in the power structures" in Miami, and there were therefore less robust ecosystems for the family to link into than was the case for Hispanic families in Miami.
''Limitations
#significant attrition was observed, ranging from 12% (3 months postrandomization) to 33% (18 months postrandomization).
#differential attrition by treatment condition was observed among African Americans
#did not include an empirically validated family therapy intervention (FAM not such an intervention)
#Should have used BSFT instead of FAM?
#it is possible that differences in dosage by ethnicity in SET and FAM may account for the present results. Thus, the observed results may be a function of how much treatment was received rather than what type of treatment was provided.

Structural Ecosystems Therapy - developed as a multisystemic development of BSFT by Szapocznik and Santisteban etc
The “ecosystemic” components of SET (e.g., parent’s relationship with an adolescent’s peers)are also influenced by
(a) Bronfrenbrenner’s theory of the social ecology (Bronfenbrenner, 1986);
(b) Hawkins and colleagues’ research on multiple domains of risk and protection
(Hawkins et al., 1992); and
(c) Henggeler and Borduin’s (1990) research on multisystemic therapy with behavior problem adolescents.
Ecological interventions included
(a) joining with membersof the ecology,
(b) tracking ecological relationships,
(c) reframing problems in the ecology, and
(d) restructuring ecological relationships.
See [[Szapocznik et al 2000]]
[[Robbins et al 2008]]

!Adolescent Addictions conference - March 2012
CBS and THC induce psychosis-LIKE states
Longe term use incr risk do psychosis
Impairs working and episodic memory
10% users develop dependence
1% of all adults and >2 % 14-17yr olds show CBS dependence.
About 50% of 16-24 yr olds have tried it
Most get only transitory side effects...
What determines whether a individual is vulnerable to harmful effects of CBS
Age at first use
Level of use
Genetics (uncertain)
Psychosis-proneness - a continuum across the Population
!Variants in CBS subtypes
Main ingredient is THC
Other is Cannabidiol (CBD) - is probably anti psychotic and neuroprotective... An inhibits reputable and hydrolysis of anandamide (endogenous cannabinoids) - ananda = bliss in oriental religious terminology...
!Hair samples
Good objective measure 3cm = 3 months
140 people:
20 had THC only
26 THC and CBD
86 neither,
8 CBD only
People with THC only had much higher rates of hallucs and delusions, and less anhedonia
THC and CBD - no differences from no-THC
!600 individuals
Used for >1 year
Tested twice, once when intoxicated with own CBS and once when NOT Intoxicated
Multiple assessments
Low CBD compared with high CBD compared
* many non-differences
* CBD BLOCKED Memory impairment of THC
* potential memory enhancer?
!response to cannabis stimuli
Pictures testing attetional bias
Skunk much more powerful attentionsl bias
!effects
No effect to level of 'stonedness' Whether CBD present or not.
!psychosis
Higher psychosis-like synptomatology in THC only group
Memory generally aided by presence of CBD
Dependency (craving, and time to smoke an eighth) - much higher in Skunk
!cerebrospinal fluid
Signif difference between light and heavy users
Light use //enhances// presence of Anandamides.
Heavy users //deplete// endogenous cannabinoids.
!Where has all the CBD gone?
CBS has changed ++++ especially in terms of reduced CBD
Skunk is bad for you
MUSIC and Change - rap is being written to persuade kids to avoid skunk.

quote from [[Diamond et al 2006]]...
“Overall, they found a moderate effect size (.22), similar to those found in the adult literature, demonstrating that measures of alliance and the therapeutic relationship are predictive of outcome. The association was not moderated by age, behavioral versus non-behavioral treatment, therapy modality, or manualized versus non-manualized treatment. ''In contrast to adult studies, therapist report of alliance was a stronger predictor of outcome than patient report. Furthermore, they noted that child-reported alliance tended to cluster at the positive end of ratings,10 indicating a tendency for appraisals to be positively biased. Also in contrast to adult studies, later alliance ratings had a stronger
relationship with outcome than those taken earlier in treatment''.”
Not reviewed therefore only 1Star

Engaging Young ''Probation-referred'' Marijuana-abusing Individuals in Treatment: A Pilot Trial
Young marijuana abusers rarely seek treatment themselves and are difficult
to engage in treatment when referred by social agencies. To evaluate treatment
engagement strategies in this population, 65 young probation-referred
marijuana abusers were randomly assigned to either three-session
motivational enhancement therapy (MET alone) or three-session
MET plus contingency management (MET/CM), with vouchers for
treatment attendance. A significantly higher number of participants in
the MET/CM condition completed the three-session intervention as compared
with MET alone. Participants in both conditions reported significant reductions in marijuana use and improvement in legal problems.
These findings suggest that young marijuana abusers benefit from
scientifcally validated treatments. (Am J Addict 2003;12:314^323)
18 - 25 yr olds
too old
from publicly funded outpatient
CM allowed earnings up to $120 for three session attnedances ($5 bonus for turning up within 5 mins of start time)
manualised
NO no-treatment control (MET Vs MET/CM)
Results:
signficantly higher number of participants in the MET/CM condition completed treatment in 28 days as compared to participants in the MET alone condition (64% vs. 39%, X2=3.85, p<.05).
No treatment effects from main condition (i.e. CM pts didn't do better than non-CM ones)

Ecologically based family therapy outcome with substance abusing runaway adolescents
Natasha Slesnick, Jillian L. Prestopnik
''Runaway youth report a broader range and higher severity of substance-related, mental health and
family problems relative to non-runaway youth''.
In a recent review, Robertson and Toro
(1999) report findings that 48% of a street sample of homeless youth met diagnostic criteria for
alcohol disorder, and 39% met criteria for other drug disorders. In comparing a NewYork City
sample of runaways to adolescents in general (using NIDA data, 1991), Koopman, Rosario, and
Rotheram-Borus (1994) report that runaways are three times more likely to use marijuana (43%
vs. 15%), seven times more likely to use crack/cocaine (19% vs. 2.6%), five times more likely to
use hallucinogens (14% vs. 3.3%), and four times more likely to use heroin (3% vs. 0.7%).
Studies document high rates of physical and sexual abuse (16–60%), depression, teen pregnancy,
and prostitution (Zimet et al., 1995; Johnson, Aschkenasy, Herbers, & Gillenwater, 1996).
Several studies report high rates of comorbid diagnoses among runaway and homeless youth
(Warheit & Biafora, 1991; Schweitzer & Hier, 1993; Unger, Kipke, Simon, Montgomery, &
Johnson, 1997).
Most studies to date have collected self-report data on the family and social history; virtually no research has examined treatment effectiveness with this population.
This study is a treatment development project in which ''124 runaway youth'' (from runaway shelters in Albuquerque, New Mexico) were ''randomly assigned'' (by urn randomisation) to
(1) ecologically based family therapy (EBFT) or
(2) service as usual (SAU) through a shelter.
''up to $150 recompense for attending sessions/assessments''
In the EBFT condition, follow-up rates were as follows: 60/65 (92%) at posttreatment, 58/65 (89%) at 6 months, and 58/65 (89%) at 12 months. In the SAU condition the rates were somewhat lower: 48/59 (81%) at posttreatment, 49/59 (83%) at 6 months, and 52/59 (88%) at 12 months
''Outcome measures:''
Youth completed asessments (TLFB/"Form 90" and urinalysis (1st f/up) and POSIT and multi other valid instruments) at:
#intake,
#posttreatment,
#6 months follow-up assessment
#12 months follow-up assessment.
''Intervention''
[[EBFT]] - manualised
''Results'':
#Youth assigned to EBFT reported greater reductions in overall substance abuse compared to youth assigned to TAU, (altho //Intent to Treat analysis// (the 53 EBFT, 44 TAU subjects who completed all assesst points even if they didn't get much therapy) found no main effects for time and treatment modality effects, when youth who //had received a set no. of doses of Rx// (at least 4 Rx sessions) were examined (42 EBFT, 44 TAU) significant differneces between EBFT and TAU were found for all drugs (excl tobacco/alc) and CBS ...(overall substance use (tobacco use not included; F(3,81)= 2:91; p<0:05; eta2=0:10), for use excluding tobacco and alcohol (F(3,81)= 2.89, p=0.05; eta2=0.10), and for percentage days of marijuana use(F(3,81)= 2.84; p=0.05; Eta2= 0.10)
#Youth with physical and sexual abuse Histories did better in EBFT than TAU
#While //other problem areas// improved in both conditions.
Findings suggest that EBFT is an efficacious intervention for this relatively severe population of youth.

"Treatment outcome for street-living, homeless youth"
(A)CRA in Rx of homeless substance using Youth
n=180 homeless youth aged 14 - 22yrs (note age) at Albuqyerque's homeless shelter, with DSM IV SUD (CDISC)
Recruitment began on 11/2/01 and ended on 2/21/05.
Youth were ''randomly assigned'' (computerised urn) to either :
(1) CRA (N=96) (offered 12 CRA therapy sessions and 4 HIV education/skills practice sessions... mean 6.8 sessions attended, and 18 subjects (c. 1/5 of allocated patients) allocated to CRA attended NONE) or...
(2) TAU, (N=84)
''Rewards'' for attending asessments (survival pack at initial assessment and $50 at last assesst)
''no signif inter-group differences''.
''No Blinding of conditions in assessments''
Manualised inervention (CRA)
Videotape fidelity measures
Multiple valid outcome measures
''Results''
Youth in CRA showed a 37% reduction in substance use (from 67% days use to 43% days use), while those receiving TAU showed a 17% reduction in substance use (60% to 50% days use).
''Intention to treat analysis'' - 155/180 youths completed both pre treatment and 6/12 assessments. the 25 who //did// complete all the assessments showed //greater CBS prevalence//, and //less alcohol prevalence// and //lower HIV risk// than those who missed assessments.
Interaction between treatment and percentage days drug use (excl tobacco) at 6/12 reveals positive benefits for CRA over TAU: (F(1, 153)=5.39, p<0.05; d=0.35) - a small to medium effect. but further analysis on simple main effects youth in CRA had a greater decrease (F(1, 153)=37.29, p<0.001; ''d=1.00'') in drug use than youth in TAU (F(1, 153)=6.89, p<0.05;
d=0.41).
NB TIME EFFECTS - TAU pts improved on most measures too, but not as much as CRA.
Limitations - No blinding of assessors to Rx condition, and only assessed at treaetment end; need longer follow up studies.

Type the text for 'Solvents'

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Author: A. Spirito, H. Sindelar-Manning, S. M. Colby, N. P. Barnett, W. Lewander, D. J. Rohsenow and P. M. Monti
Year: 2011
Title: Individual and family motivational interventions for alcohol-positive adolescents treated in an emergency department: results of a randomized clinical trial
Journal: Archives of Pediatrics & Adolescent Medicine
Volume: 165
Issue: 3
Pages: 269-74
Abstract:
!OBJECTIVE:
To determine whether a brief individual motivational interview (IMI) plus a family motivational interview (Family Check-Up [FCU]) would reduce alcohol use in adolescents treated in an emergency department after an alcohol-related event more effectively than would an IMI only.
!DESIGN:
Two-group randomized design with 3 follow-up time points.
!SETTING:
An urban regional level I trauma center. PARTICIPANTS: Adolescents aged 13 to 17 years (N = 125) with a positive blood alcohol concentration as tested using blood, breath, or saliva.
!INTERVENTIONS:
Either IMI or IMI plus FCU.
!MAIN OUTCOME MEASURES:
Drinking frequency (days per month), quantity (drinks per occasion), and frequency of high-volume drinking (>=5 drinks per occasion).
!RESULTS:
Both conditions resulted in a reduction in all drinking outcomes at all follow-up points (P < .001 for all), with the strongest effects at 3 and 6 months. Adding the FCU to the IMI resulted in a somewhat better outcome than did the IMI only on high-volume drinking days at 3-month follow-up (14.6% vs 32.1%, P = .048; odds ratio, 2.76; 95% confidence interval, 0.99-7.75).
!CONCLUSIONS:
Motivational interventions have a positive effect on drinking outcomes in the short term after an alcohol-related emergency department visit. Adding the FCU to an IMI resulted in somewhat better effects on high-volume drinking at short-term follow-up than did an IMI only. ''The cost of extra sessions necessary to complete the FCU should be weighed against the potential benefit of reducing high-volume drinking when considering adding the FCU to an IMI for this population.''

Spirito, A, Monti, PM, Barnett, NP, Colby, SM, Sindelar, H, Rohsenow, DJ, Lewander, W, and Myers M, (2004)
!“A randomized clinical trial of a brief motivational intervention for alcohol-positive adolescents treated in an emergency department.”
Journal of Pediatrics;145:396-402
Alcohol RCT
single 35 - 45 min MI session Vs. a 5 min "Standard Care" session.
$20 payment after session.
3, 6, and 12/12 follow-up with 15, 15 and $25 payments as rewards.
"The study was described to 287 eligible patients, but 134 (47%) declined to participate or were discharged from the ED before completion of recruitment, resulting in 152 participants.The sample consisted of 97 boys (63.8%) and 55 girls (36.2%) with an average age of 15.6 years (SD = 1.2). Low pickup rate on ITT..."
RCT, low reruitment and risk of hawthorn effect and bias due to financial inducements.
Standardised outcome measures incl Alcohol use, Drinking and Driving incidents, alcohol-related injuries, alc related problems.
"There was no effect on frequency of intoxication or negative alcohol-related consequences. Nonetheless, the positive effects appear clinically
significant with average number of drinking days per month
about 4 in the MI group compared with 7 in the SC group at
one year, and high-volume drinking days reduced by almost
half at 12 months in the MI group compared with the SC
group.""
Benefits only if adolescent reported problem drinking at baseline... similar to [[McCambridge and Strang 2004]] - most beneficial for those with highest probs - but not about abstaining - just harm minimisation."

Spirito A, Sindelar-Manning H, Colby SM, Barnett NP, Lewander W, Rohsenow DJ, Monti PM (2011) ''Individual and Family Motivational Interventions for Alcohol-Positive Adolescents Treated in an Emergency Department: Results of a Randomized Clinical Trial'' Arch Pediatr Adolesc Med. 2011;165(3):269-274
!Abstract
!!!Objective:
To determine whether a brief individual motivational
interview (IMI) plus a family motivational interview
(Family Check-Up [FCU]) would reduce alcohol
use in adolescents treated in an emergency department
after an alcohol-related event more effectively than would
an IMI only.
!!!Design:
Two-group randomized design with 3 follow-
up time points.
!!!Setting:
An urban regional level I trauma center.
!!!Participants:
Adolescents aged 13 to 17 years (N=125)
with a positive blood alcohol concentration as tested using
blood, breath, or saliva.
!!!Interventions:
Either IMI or IMI plus FCU.
!!!Main Outcome Measures:
Drinking frequency (days per month), quantity (drinks per occasion), and frequency
of high-volume drinking (> or = 5 drinks per occasion).
!!!Results:
Both conditions resulted in a reduction in all drinking outcomes at all follow-up points (P<.001 for all), with the strongest effects at 3 and 6 months.
Adding the FCU to the IMI resulted in a somewhat better outcome than did the IMI only on high-volume drinking days at 3-month follow-up (14.6% vs 32.1%, P=.048; odds ratio,
2.76; 95% confidence interval, 0.99-7.75).
!!!Conclusions:
Motivational interventions have a positive
effect on drinking outcomes in the short term after
an alcohol-related emergency department visit.
Adding the FCU to an IMI resulted in somewhat better effects on high-volume drinking at short-term follow-up than did an IMI only.
The cost of extra sessions necessary to complete the FCU should be weighed against the potential benefit of reducing high-volume drinking when considering adding the FCU to an IMI for this population.

Reducing STD and HIV Risk Behavior of Substance-Dependent Adolescents: A Randomized Controlled Trial
A randomized controlled trial assessed 3 interventions designed to increase safer sex behaviors of
substance-dependent adolescents.
!Participants (N = 161) recruited from adoelscent residential drug Rx units
Mean age 16yrs, 2/3 male, 1/3 female
approx 3/4 caucasian, 1/4 African american
Mississippi, a state with high rates of adolescent STD, HIV, and pregnancy
Mississippi ranked first nationally in births to teenagers, teenage pregnancy, and
syphilis and third nationally in gonorrhea incidence. One third of gonorrhea
cases were diagnosed in 15- to 19-year olds, more than in any other age
group (Mississippi State Department of Health, 1995)
!!WOW!!
This __motivational manipulation__ was added to address personal perceptions
of risk and to motivate participants to practice safer sex or abstinence,
using a developmentally appropriate and emotion-based strategy.
The emotion-based strategy was implemented as follows: A photograph
of each participant was taken at baseline, using a digital camera. The image
was downloaded into a computer and a color print of the photo was made.
The computer image was then electronically transformed to visually depict
how the adolescent might appear in end-stage AIDS (e.g., extreme wasting,
Kaposi’s sarcoma lesion on his or her face).
received 12 sessions of either
#a health information intervention (I only),
#information plus skills-based safer sex training (I+B), or
#the same experimental condition plus a risk-sensitization manipulation (I+M+B).
The I+B and I+M+B conditions, as compared with the I only condition,
(a) produced more favorable attitudes toward condoms;
(b) reduced the frequency of unprotected vaginal sex; and
(c) increased behavioral skill performance, frequency of condom-protected sex, percentage of intercourse occasions that were condom
protected, and number of adolescents who abstained from sex. The intervention that included the
risk-sensitization procedure was more resistant to decay.
An unexpected finding was that the I + B and
I + M+B conditions produced substantial increases in sexual abstinence.

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Stein, LAR, Colby, SM, Barnett, NP, Monti, PM, Golembeske,C, Lebeau-Craven,R, (2006)
!“Effects of Motivational Interviewing for Incarcerated Adolescents on Driving Under the Influence after Release”.
The American Journal on Addictions, 15: 50–57.
Alcohol and CBS
"The purpose of this study was to explore the
impact of depressed mood on treatment to reduce DUI
and being a passenger with a driver under the influence
(PUI) in substance using incarcerated adolescents.
Using 2 sessions of M.I. Vs Relaxation therapy"
Initial (90min) Session and Booster (c.60min) sessions of M.I
Vs.
Single session of Relaxation therapy
"All Adolescents incarcerated in a large State Juvenile Correction cenre in the N.E of USA were screened.
Of 125 adolescents approached for the study, all met screening criteria and completed consent procedure.
Of those 125, two adolescents dropped out of the study prior to completing the initial assessment.
Of the remaining 123, 105 were re-interviewed at 3-month follow-up; 15 could not be located for follow-up after release
from the facility, and three adolescents withdrew from the study prior to completion of the 3-month follow-up.
Sample (N = 105) was comprised of 27.6% Hispanic, 34.3% African American, 32.4% White, and 5.7% other.
Most were boys (89.5%), and average age was 17.06 years (standard deviation ¼ 1.08).
In the last year, 61.0% and 84.8% qualified for alcohol and marijuana use disorders, respectively.
Over 41% of the sample had been previously incarcerated.
Eighty-nine and one-half percent (89.5%) of the sample enrolled in the usual substance use programming
offered at the facility (see description below),
following our initial treatment at baseline."
Single follow up point at 3/12.
Financial inducements (up to $70)
Manualised training for therapists in both modialities (56 hours). SCID- I, CES-D (Centre for Epidemiological Studies - Depression scale) and others. Risky Behaviours Questionaire. Validated measures.
"In contrast to [[McCambridge and Strang 2004]] - effects most pronounced for LOW depression scores adolescents -
At high depressive symptoms, no differences were found between treatment groups; "
"The clinical significance of these findings is of interest:
For adolescents low in depressive symptoms early in incarceration,
at 3 months after release the MI group showed
an 89.1% reduction in DUI-A(Driving under the influence - alcohol), and a 74.2% reduction
in PUI-A (passenger of driver under the influence - alc) as compared to the RT group.
Although similar reductions in DUI-Mj (Marijuana) and PUI-MJ were observed, they
were non-significant at the .05 p-level."

"Family based therapy plus cognitive behavioural therapy alone for reducing adolescent drug abuse therapy (CBT) was better than CBT alone or family"
Evid. Based Ment. Health 2002;5;53-
Reviewing [[Waldron et al 2001]] - see Stevens brief paper (EBMH reveiw - one page) for details
In the past decade many studies have investigated the efficacy of various treatment models
among adolescent substance abusers. Of the handful of promising models, only a few have
been identified as exemplary. These models are appropriately theory driven, based on the
previous identification of risk and protective factors for substance abuse, and are empiri­
cally supported by randomised controlled trials (RCTs). Family based models such as
multidimensional family therapy and multisystemic therapy meet this standard of
excellence.1 Other promising family, group, and individual based models include FFT, the
more traditional 12 step model, motivational enhancement therapy, and CBT.
The study by Waldron et al represents the first systematic investigation of FFT in that
it presents the results of an RCT with comparisons between FFT and other treatments.
It provides evidence that FFT, particularly in combination with CBT, is efficacious in
treating substance abusing adolescents. The long term persistence of the treatment
effect remains to be determined. An interesting and unexpected finding was the positive
effect at 7 months with the psychoeducational treatment group. This finding requires
further study, given that it is less costly than the more intensive interventions.
Although the generalisability of the findings to the population at large is limited
because the adolescents were primarily boys who had juvenile justice involvement, pre­
sented with marijuana abuse/dependency, and were treated in an outpatient setting, it
is interesting to note that approximately 50% were Hispanic, which supports the effec­
tiveness of this treatment model among this population.
In general, the results of this RCT show that FFT, particularly in combination with
CBT, is efficacious for treating adolescents who meet DSM­IV criteria for substance
abuse. More specifically, this study shows the efficacy of this combined treatment
approach among a population of adolescent male substance abusers (Hispanic and
Anglo–American). However, further studies of FFT are warranted where larger samples
are included, subgroups are identified within which this therapy is particularly
efficacious, and site effects are examined.

!Polishing
See [[ToDo]]
!Summary bullet points
#Substantive conclusions about the level of support for treatments covered in the chapter
#Mention treatment, condition, and population
#Standardised language across conclusions
*Absence of evidence:
**‘There is no systematic evidence for or against the use of treatment T for condition C in population P’
* Strong evidence in favour:
**‘There is strong evidence to support the use of treatment T for condition C in population P’
* Strong evidence against:
**‘There is strong evidence that treatment T for condition C in population P is ineffective’
* Conflicting evidence:
**‘There is conflicting evidence for the use of treatment T for condition C in population P’
***Briefly elaborate the conflict
****Evidence in need of qualification:
****'There is limited/some evidence to support the use of treatment T for condition C in population P.’
***Explain the way in which the evidence is limited
***Number, type, size, duration, site-number and location of studies
!Implication bullet points
*Treatment recommendations based on summaries of evidence
*Make the link to evidence clear with the use of phrases such as:
>//"Given the evidence for/importance of ... we suggest ''x''"//

Kah Mirza refers to a "celestial gardener" making the system work more efficiently!

Treatment Episode Data Set (TEDS) 2002
Discharges from Substance Abuse Treatment Services
Office of Applied Studies (OAS). Treatment Episode Data Set
(TEDS) 2002: Discharges from Substance Abuse Treatment Services.
Rockville, MD: Substance Abuse and Mental Health
Services Administration; 2005. (accessed 16.06.08)
Massive data set of treatment episodes:
"The report provides information on treatment
completion, length of stay in treatment, and
demographic and substance abuse characteristics
of approximately 800,000 discharges from
alcohol or drug treatment in facilities that report
to individual State administrative data systems.
The Office of Applied Studies (OAS), Substance
Abuse and Mental Health Services Administration
(SAMHSA), coordinates and manages
collection of TEDS data from the States."
@@''Discharges who were 17 years of age or
older at first use of the primary substance
(vs. those who were younger) were 23
percent more likely to complete treatment
or transfer to further treatment.''@@

A systematic review of the effectiveness of brief interventions with substance using adolescents by type of drug
Up to 2002 papers
Found 11 papers
Seven papers reported outcomes for alcohol interventions and
Four involved other substances (including one with separate alcohol outcomes).
The overall effect size was d = 0.126 with borderline homogeneity (Q=14.9, df = 9, p= 0.09).
[NB a very small effect size: Different people offer different advice regarding how to interpret the resultant effect size, but the most accepted opinion is that of Cohen (1992) where 0.2 is indicative of a small effect, 0.5 a medium and 0.8 a large effect size.]
The effect size from the eight alcohol interventions (n = 1075) was classified as significant but ‘‘small’’
(d = 0.275).
The remaining non-alcohol studies were considered separately as interventions involving tobacco or multiple
substance use.
The two interventions with ''tobacco'' involved a substantial sample (n =2626) but had a ''very small effect'' (d = 0.037),
...while the two interventions addressing ''multiple substances'' //involved few participants// (n =110) but had a ''medium – large effect'' (d = 0.78).
Across a diverse range of settings (dental clinic, schools, universities, substance treatment centres) and,
therefore, probably diverse clients, BI conferred benefits to adolescent substance users. BI had a small effect on alcohol consumption
and related measures. The data for tobacco interventions suggested a very small reduction, particularly with general community
interventions.
The effect of BI with multiple substances appears substantial but the small sample cautions against expansive generalization.

Tait RJ, Hulse GK, Robertson SI, Sprivulis PC, (2005)
!“Emergency department-based intervention with adolescent substance users: 12-month outcomes”
Drug and Alcohol Dependence 79, 359–363
Polysubs
"emergency brief intervention for adolescents seen in emergency dept for alcohol or other drug (AOD) related emergencies.
The aim of the intervention was to match the needs of the adolescent with an
appropriate treatment agency, to motivate the adolescent to
attend an appointment and to remove any barriers that might
reduce the likelihood of attendance."
intervention included referral (in Rx Group as opposed to TAU) to sessions, with phone call and offer of transport or accompanying the YP to first appt. Check 2004 paper.
127 adoelscents. Atteding A&E for emergency relating to SUD. Nature of SUD not made clear: just an incident/emergency relating to AOD use..
RCT, Intention to treat analysis,
Measures: Reattendance at ED, engagemtn in Rx, GHQ-12, etc...
Improved engagment in SUD treatment, reduced ED events, improved GHQ-12 scores.

CBS
Piggy back onto the [[CYT]]
Looking at associations between TREATMENT SATISFACTION, and WORKING ALLIANCE… and outcomes post treatment.
Adult studies suggest Rx Satisfaction asociated with +ve outcome.
Ditto adult studies on alliance - tho it was alliance at 3/12 into Rx (not in first few weeks) that correlated +vely.
Diff Rx's compared. Similar 'doses'. See CYT
Not Rx trial per se. Manualsied Rx's.
Measures of Treatment Alliance and Satisfaction, and other measures of wellbeing and SUD - no relapse/mild relapse/mod relapse/severe relapse
!!Treatment SATISFACTION is NOT predictive of outcome success/failure.
!!Working Alliance is only weakly predictive in the early stages post-treatment (3 and 6/12 f/up)
At long term follow up nearly half the sample had made improvement (abstinent or unsteady improvement), but at 30/12 just OVER HALF had got worse - trends towards heavier use... and not predicted by either Treatment satisfaction of Working alliance...
Where there was some predictive value it was with working alliance and the mild-mod relapse groups (better W.A. - less relapse) but for the Severe Relapse Group... no relation... ?becasue so many other factors implicated in this small group?
Worth of measuring Rx Satisfaction.. at all? Seems worth it, but for obvious reasons other than Rx effectiveness...

multiple substances Review -
very good summary of brief interventions and M.I. for adolescents
Brief Rx's - Review - adolescent studies
From Tevyaw 2004:
“As defined by Miller & Sanchez (1994), the common elements of effective brief interventions are
represented best by the acronym FRAMES:
#Personalized ''Feedback'' or assessment results detailing the target behavior and associated effects and consequences on the individual;
#emphasizing the individual’s personal ''Responsibility'' for change;
#giving ''Advice'' on how to change;
#providing a ''Menu'' of options for change;
#expressing ''Empathy'' through behaviors conveying caring,understanding and warmth;
#and emphasizing ''Self-efficacy'' for change and instilling hope that change is not only possible but also within reach.”
One brief intervention is M.I…..
“As Miller (1996) and Miller & Rollnick
(2002, 1991) have said, the term ‘motivational interviewing’
pertains both to a style of relating to others and
a set of techniques to facilitate that process. Its five main
tenets include:
1. an empathic, non-judgemental stance,
2. listening reflectively;
3. developing discrepancy,
4. rolling with resistance and avoiding argument; and
5. supporting self-efficacy for change.”
The theoretical basis of motivational enhancement
and motivational interviewing is grounded in clientcentered
therapy, social learning theory and cognitive–
behavioral therapy
Thorough review of Rx studies - broadly supportive of effectiveness of brief interventions
''"results particularly strong for those with heavier substance
use patterns and/or less motivation to change." ''

!use of sex hormones by young LGBT population
Increasing issue with young in Manchester
!Cigarettes
Easy to overlook. Disease of poverty...
Girls more likely to take up smoking than boys...
!2009/10 increase in drugs offences in youth
May represent reclassification of CBS...

Thurstone C, Riggs PD, Salomonsen-Sautel S, Mikulich-Gilbertson SK (2010) ''Randomized, Controlled Trial of Atomoxetine for Attention-Deficit/Hyperactivity Disorder in Adolescents With Substance Use Disorder.'' J. Am. Acad. Child Adolesc. Psychiatry, 2010;49(6):573–582.
!Conflicts of interest - none
This project was funded by the American Academy of Child and Adolescent Psychiatry Physician Scientist Program in Substance Abuse K12 Award (DA 000357-06AK12) and National Institute on Drug
Abuse grants U10 DA013732, DA012845, and 5R01DA022284.
Drs. Thurstone, Riggs, and Mikulich-Gilbertson, and Ms. Salomonsen-Sautel report no biomedical financial interests or potential conflicts of interest.
Medication and matching placebo were supplied by Eli Lilly.
!Abstract
!!!Objective:
To evaluate the effect of atomoxetine hydrochloride versus placebo on attentiondeficit/
hyperactivity disorder (ADHD) and substance use disorder (SUD) in adolescents
receiving motivational interviewing/cognitive behavioral therapy (MI/CBT) for SUD.
!!!Method:
This single-site, randomized, controlled trial was conducted between December 2005 and
February 2008.
Seventy adolescents (13 through 19 years of age) with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) ADHD, a DSM-IV ADHD checklist score greater than or equal to 22, and at least one nontobacco SUD were recruited from the
community.
All subjects received 12 weeks of ''atomoxetine hydrochloride'' + ''MI/CBT'' versus
''placebo'' + ''MI/CBT''.
The main outcome measure for ADHD was self-report DSM-IV ADHD checklist score.
For SUD, the main outcome was self-report number of days used nontobacco
substances in the past 28 days using the Timeline Followback interview.
!!!Results:
Change in ADHD scores ''__did not differ between__'' atomoxetine + MI/CBT and placebo + MI/CBT (F4,191 = 1.23, p = .2975).
Change in days used nonnicotine substances in the last 28 days ''__did not differ__'' between groups (F3,100 = 2.06, p = .1103).
!!!Conclusions:
There was no significant difference between the atomoxetine + MI/CBT and placebo + MI/CBT groups in ADHD or substance use change.
The ''//MI/CBT and/or a placebo effect may have contributed to a large treatment response in the placebo group//''.

From [[Dawes and Johnson 2004]]:
Pre-synaptic serotonin reuptake enhancers: tianeptine. In
contrast to SSRI, tianeptine enhances pre-synaptic 5-HT
reuptake, decreasing 5-HT availability at the post-synaptic 5-HT
receptor (Curzon et al., 1992). Acutely, tianeptine increases
5-HT uptake in brain synaptosomes (cortex and hippocampus)
(Mennini et al., 1987; Fattaccini et al., 1990), as well as platelets
(Chamba et al., 1991), presumably with the long-term effect of
decreasing serotonin turnover. In addition, chronic tianeptine
treatment decreases the stress response of the hypothalamic–
pituitary–adrenal axis, and modulates neuroendocrine response
to cytokines (Castanon et al., 2003; Nickel et al., 2003).
Tianeptine’s mechanisms of action would, therefore, make it a
promising medication for treating anxiety-related and affective
disorders.
Thus it is of interest that tianeptine has been shown to be
effective in adults for the treatment of depression with comorbid
alcohol misuse or dependence. In a double-blind, placebocontrolled
study, tianeptine treatment significantly improved
depression after withdrawal compared with placebo (Lôo et al.,
1988). Tianeptine does not appear promising for the treatment
of non-depressed alcohol-dependent individuals. For instance,
in a multi-centre, double-blind, controlled trial, tianeptine
(12.5 mg t.i.d.) showed no difference from placebo after 9 months
of treatment (n = 327) (Favre et al., 1997).
Notably, the use of tianeptine has been piloted as a
treatment for adolescent alcohol use disorders. ([[Niederhofer et al (Tianeptine) 2003]]) reported on a study of 26 adolescent inpatients
with alcohol use disorders, aged 16–19 years, assigned
randomly to 37.5 mg of tianeptine or placebo for 90 days. All
subjects received psychotherapy three times per week,
physiotherapy and ergotherapy. Continuous abstinence and
cumulative abstinence duration were significantly greater for
the tianeptine group compared with placebo. This study did
not, however, report the comparative length of inpatient versus
outpatient care for the two treatment groups. It is therefore
tempting to speculate that tianeptine may be effective in
adolescents with alcohol use disorders, compared with their
adult counterparts, because it treats their relatively higher level
of subsyndromal anxiety-related and affective disorders

Note that many of the [[Pharmacology]] trials obtain trends towards significant effects re reaching abstinence, but signicificnat effects re REDUCTION in use of cigarrettes and this itself may be a predisposing facotre for successful cessation at a later date...

The worth of urine testing ([[Latimer et al 2003]]) – (it makes subjects tell the truth in questioning!)
"urinalysis results were rarely useful for detecting the recent use of substances other than marijuana because of the inability of urine testing to detect even heavy alcohol use within the past 24 hours and because rates of recent drug use other than alcohol or marijuana were uniformly low across referred youth. Nonetheless, rates of concordance between youth self-report of substance use during the past month and urinalysis results exceeded 95% at baseline and each follow-up assessment point. Thus, collection of urine samples likely improved the validity of youth self-report of recent substance use even though the urinalysis results themselves rarely added information that assisted with making a diagnostic decision. Rather, the value of collecting urine samples appeared to involve engendering the accurate impression by our youth participants that mis-representation of their recent substance use would likely be detected."

"On the learning curve: the emerging evidence supporting cognitive–behavioral therapies for adolescent substance abuse"
Addiction, 99 (Suppl. 2), 93–105
Good review of hiugh quality studies - 5Star
__Theories:__
"Not a unitary approach"
Behaviourist - conditioned responses
operant conditioning
Social Learning
''Reviews main controlled trials of CBT in which:''
(1) at least one form of CBT was compared to one or more other comparison conditions;
(2) substance use was measured through self-report and/or biological assay as a primary outcome variable;
(3) participants were assigned randomly to treatment;
(4) treatments were manual-guided;
(5) samples were clearly specified
#[[Liddle et al 2001]]- MDFT and CBT showed improvements but these seemed better sustained in MDFT group than CBT at 12/12.
#[[Waldron et al 2001]] - 4 Rx's: CBT, Behavioural Group, FT, combined FT + CBT. behaviural gp - dealyed but substantial improvts, EFFECT SIZE FOR THE GROUP BEHAVIOURAL Rx at 19/12 was 0.93... only 0.67 at the same time point for the FAMILY INTERVENTION... Individual CBT - better initial ABSTINENCE rates (early.. but theses died away by the 7/12 follow up.
#and Waldron reports "a second trial already under way" ("Of the 160 adolescents to be enrolled in the trial, 45 have completed treatment and 5-and 8-month follow-up assessments")
#[[Liddle 2002]] - CBT VS MDFT - both did well but MDFT gains continued while indiv CBT levelled off
#[[Kaminer et al 2002]] - at 3/12 CBT better than PET, but similar gains at 12/12
#[[Dennis et al 2002]] - the CYT MET/CBT came out as best value for money.
''Re the Individual Vs Group Question'' - cf. [[Dishion et al 1999]]
"Dishion and colleagues focused their research
efforts on preventive interventions for youths who were
at risk for substance use, not for those who had already
developed a substance use disorder as in each of the samples
of the treatment outcome studies reviewed. The negative
consequences experienced by adolescents diagnosed
with substance abuse or dependence would be expected
to influence treatment motivation."
''Re. Rx of Comorbidity''
CBT effective in getting quick gains in, say depression
''Re. MECHANISMS OF CHANGE''
"studies examining the efficacy of
various components of CBT to elucidate mechanisms of
change or therapy-process variables associated with
change are virtually nonexistent in youths"...

Waldron HB, Slesnick N, Brody JL.Treatment outcomes for adolescent substance abuse at 4– and 7–month assessments.
J Consult Clin Psychol 2001 Oct;69:802–13
@@NB reviewed in [[Waldron and Kaminer 2004]]@@
@@Very good summary of findings in [[Stevens 2002]] - EBMH@@
__CBS Rx's__ other drugs were looked at but usage rates were not large enough to draw conclusions
CBT (+ 2 MET)
Vs
FFT = Functional Family therapy
Vs
integrated FFT and CBT
Vs
Group = Drug and Education -based similar to preventative models
Manualised Rx's
Range of validated outcome measures incl CBCL, TLFB, urine drug screens
12 hrs therapy in each condition, and 24hrs in joint condition, and up to 2 hrs additional to resolve crises
114 out of 120 referred. 13 - 17 yr oldsliving at home with promary carer willing to pasticipate.
//Most adolescents mandated to attend by court or school//
89.8% at or above mean scores of delinquent behaviour in comparison group of referred adoelscents, similarly 29.7% anxious/depressed, etc. but excluded if needed other than OP provision, sibling in study, considered 'enrolled' if attended one session.
Smallish no.s (114) no placebo (unethical), randomised.
All intervetions have positive effects sizes:
individual modailites:
[[FFT]] is based, in large part, on
family systems theory, which assumes that problem
behaviors occur in the context of family relationships and
serve some core function within these family relationships.
In addition to a family systems perspective, the
FFT model relies heavily on cognitive behavioral theory
and techniques. FFT takes a multisystemic approach to
intervention by focusing on the multiple domains and
systems in which the adolescent lives.
!results:
FFT consistently best results: change in heavy to minmal use from pre-Rx to 4/12 post-Rx - 86.6% vs 55.2%, z=2.89. p<0.004, and at 7/12 86.6% vs 62.1%, z= 2.53, p<0.011)
FFT appears tpo promote longer lasting changes than CBT, which was good at 4/12 (heavy to minmal use from pre Rx to 4/12 post; 96.8% vs 72.4%, z=2.65. p<.008) but less good than group at 7/12)
FFT better than Group earlier on: Group do OK but only at 7/12 (96.7% vs 69.0%, z=2.53, p<.011), not at 4/12 (this contradicts [[Dishion et al 1999]] who claim group Rx has iatrogenic effects (but they were looking at preventive intervention for at risk youth, not diagnosed SUD)
!!The //Joint// FFT+CBT is best outcome, though the adolescents had twice as many sessions - but the authors point out that youths in the group intervention still reduced their intake signif at 7/12 - so not just dose dependent. (89.7% vs 55.6%, z=2.71, p<.007)
...some outcome measures change according to when they are taken - some Rx's only reveal benefit later..

CBS
"Brief ME for CBS-using adolescents recruited voluntarily (mostly - 74% - self-referral via school, after an educational presentation.)
After assessment, MET-style feedback: Feedback consisted of the
following domains:
#normative comparisons of marijuana use,
#patterns of marijuana use,
#positive and negative aspects of marijuana use,
#marijuana expectancies,
#problems related to use,
#quantity and frequency of alcohol and other drug use,
#social support,
#life goals and their relationship with marijuana use,
#costs and benefits of reducing their use, and
#self-efficacy for resisting use."
"2 sessions c. 1 week apart.
Ninety-four percent of MET participants completed Session 1, and 77% completed Session 2"
"184 screening interviews, 102 (55%) eligible, 97 consented (95% of eligible) to recruitment to study.
Criteria: Inclusion criteria were
(a) 14–19 years of age,
(b) in Grades 9–12, and
(c) used marijuana on at least 9 of the last 30 days. This frequency criterion was intended to enroll a sample of regular, that is, “more than weekend only,” users.
Participants were excluded if they
(a) were not fluent in English,
(b) showed evidence of a thought disorder that precluded participation, or
(c) refused to accept randomization to condition.
Payments: $15 per feedack session (2 for each subject) and $20 per third/final assessment"
"Trained therapists (""health educators"") and manualised Rx. Following baseline assessment, participants were stratified on stage of
change (precontemplator/contemplator vs. preparation/action/maintenance)
and grade level (9th/10th vs. 11th/12th) and then randomly assigned
to receive the intervention immediately (MET) or after a 3-month delay
(delayed feedback control [DFC])."
"Global Appraisal of Individual Needs—Initial version
(GAIN-I; Dennis, 1998) poorly defined outcome meqsures"
"Approx 1/3 of Rx and delayed Feedback Control (DFC) groups were in pre-contemplation stage of change (did well to recruit these)….
But no signif change in CBS use between groups at 3/12 F/up… although SIGNIFICANT REDUCTIONS OF CBS USE WERE FOUND ACROSS ALL GROUPS during the assesst period...
meaningful change in 45% of MET and 33% of DFC groups (non sig.) "
"Given that this program reached and engaged
a population that was otherwise not being seen, continued interest
in this program is warranted."
Limitations to these conclusions.
#Gift certificates
for participation in the intervention sessions may account for
some of the appeal, and additional studies are needed to assess
participation under different incentive conditions.
#The lack of assessment measures related to harm reduction of marijuanarelated
behaviors and the reliance on self-reports may have provided
an incomplete picture of outcomes.
#Finally, a larger sample size is needed to adequately explore differential effects in subgroups
defined by age and motivation for change, given the likelihood
of smaller effect sizes in adolescent drug users without
extrinsic motivations for change."

Pharmacotherapy of Adolescent Substance
Use Disorders: A Review of the Literature
James G. Waxmonsky, M.D.,1 and Timothy E. Wilens, M.D.2
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume 15, Number 5, 2005 pp 810 - 825
Literature Review - useful TABLES in the paper itself
Major points:
!''Bipolar:''
Youths who develop bipolar disorder in adolescence are at increased risk for early onset of substance use and development of SUD (Wilens et al. 1999, 2004). Unlike ADHD, this elevated risk for SUD appears independent of conduct disorder. Although the data are limited, our review of the literature suggests that youths with comorbid bipolar spectrum disorders appear to be the group that is most likely to respond to pharmacological interventions for SUD. Specifically, one randomized, controlled and one open study have reported that lithium and valproic acid significantly reduced substance use in bipolar youths while positively impacting functioning (Donovan et al. 1996, 1997; Geller et al. 1998). These data support the simultaneous treatment of mood disorders and SUD in youths.
!Affective disorder (Depression)
"adolescent studies have found that abstinence from substances typically does not lead to remission of depressive symptoms, as is the case for many adults (Riggs et al. 1995; Grella et al. 2001; Brown and Schuckit 1998), highlighting the need for additional mood-specific treatments in comorbidly ill youth with SUD. The limited dataset on antidepressants for adolescents
with MDD and SUD demonstrates that these medications can be safely implemented and generally well tolerated with no evidence
of worsening moods. However, the efficacy data are mixed. Open trials of fluoxetine and bupropion have observed significant reductions in depressive symptoms and associated improvements in SUD symptoms (Cornelius et al. 2001, 2004b, 2005; Riggs et al. 1997; Solhkhah et al. 2001). However, the one controlled study (n = 10) addressing this issue (Deas et al. 2000) found that the addition of sertraline to group CBT did not lead to greater improvements in mood or SUD symptoms. However, the small
N, the dosing paradigm (maximum dose, 100 mg) and the robust response to the CBT intervention may have limited the medication effect." - @@NB give same warings as for SSRI's etc in non-SUD depression@@
!ADHD
"The literature is mixed regarding the impact of ADHD treatment in youths with SUD. Three open studies (n = 31) and one controlled study (n = 69) have shown that pharmacotherapywith pemoline or bupropion improves ADHD symptoms in youths with active SUD (Riggs et al. 1996; Riggs et al. 1998b; Riggs et al. 2001; Solhkhah et al. 2001).
Similar to studies in adults (Grabowski et al. 1997; Schubiner et al. 2002; Wilens 2004), the data do not show a convincing
reduction in SUD symptoms and, therefore, support the earlier recommendation by Riggs (Riggs 1998a) that ADHD pharmacotherapy
should be delayed until the SUD has been addressed. However, the differential outcomes of ADHD pharmacotherapy in stabilized
versus unstabilized SUD youths needs to be further evaluated....
If ''stimulants'' are to be used for adolescents with SUD, ''extended-release preparations'' may be less likely to be abused than those with a shorter duration (Ciccone 2002; Jaffe 2002). Atomoxetine, bupropion, and pemoline have minimal abuse liability. While bupropion and atomoxetine lack significant interactions with substances of abuse, pemoline has been associated with hepatic toxicity in non-SUD patients. Therefore, ''pemoline is not recommended as a first choice for youths with SUD''.
''Atomoxetine'' is FDA-approved for both pediatric and adult ADHD and appears to have minimal abuse potential (Heil et al. 2002). Therefore, it should be considered as a possible alternative to stimulant treatment in youths with ADHD and SUD,
but formal treatment studies of atomoxetine in youth with these comorbidities are needed."
!Anti-craving medication
"The anticraving agents, such as naltrexone, acamprosate, bupropion, and ondansetron, may have a potential role in the treatment of youths with SUD. Case reports suggest that ''naltrexone'' may reduce alcohol craving in adolescents with SUD (Wold et al. 1997; Lifrak et al. 1997), but there are no controlled data at present.
''Acamprosate'' was recently approved for use in adults with alcohol dependency, and there is one published trial in adolescents (Niederhofer and Staffen 2003b).
''Bupropion'' has been approved for smoking cessation in adults and may be similarly helpful in adolescents (Moolchan et al. 2000). However, several open studies have produced mixed results when assessing bupropion’s efficacy for craving reduction for other substances of abuse in psychiatrically ill adults and teens (Riggs et al. 1998; Levin et al. 2002; Prince et al. 2002; Solhkhah et al. 2001).
Preliminary findings in adults with early-onset SUD suggest that ''ondansetron'' may be similarly useful for craving reduction in youths with SUD (Johnson et al. 2000b, 2002, 2003b; Kranzler et al. 2003). Moreover, it appears to be adequately
tolerated by youths (Toren et al. 2005), making it a good candidate for further investigation as a SUD treatment in adolescents..... Larger controlled trials are warranted in youths, including those of promising pharmacological agents for the treatment of adult SUD, such as ondansetron and acamprosate."

Pediatrics 2003;111;179-185
Does Stimulant Therapy of Attention-Deficit/Hyperactivity Disorder Beget Later Substance Abuse? A Meta-analytic Review of the Literature
Timothy E. Wilens, Stephen V. Faraone, Joseph Biederman and Samantha Gunawardene
META-ANALYSIS
!ABSTRACT.
''Objective''.
Concerns exist that stimulant therapy of youths with attention-deficit/hyperactivity disorder (ADHD) may result in an increased risk for subsequent substance use disorders (SUD). We investigated all long-term studies in which pharmacologically
treated and untreated youths with ADHD were examined for later SUD outcomes.
''Methods.''
A search of all available prospective and retrospective studies of children, adolescents, and adults with ADHD that had information relating childhood exposure to stimulant therapy and later SUD outcome in adolescence or adulthood was conducted through PubMed supplemented with data from scientific presentations. Meta-analysis was used to evaluate the relationship
between stimulant therapy and subsequent SUD in youths with ADHD in general while addressing specifically differential effects on alcohol use disorders or drug use disorders and the potential effects of covariates.
''Results.''
Six studies — 2 with follow-up in adolescence and 4 in young adulthood were included and comprised 674 medicated subjects and 360 unmedicated subjects who were followed at least 4 years. The pooled estimate of the odds ratio @@indicated a 1.9-fold reduction in risk for SUD in youths who were treated with stimulants compared with youths who did not receive pharmacotherapy for ADHD (z=2.1; 95% confidence interval for odds ratio [OR]: 1.1–3.6).
@@ We found @@similar reductions in risk for later drug and alcohol use disorders (z = 1.1).@@
Studies that reported follow-up into adolescence showed a //greater protective effect// on the development of SUD (OR: 5.8) than studies that followed subjects into adulthood (OR: 1.4)....
@@(from discussion: "Our finding of a less robust protective effect of ADHD pharmacotherapy in reducing SUD in adulthood (OR: 1.4) relative to adolescence (OR: 5.8) is noteworthy. Although data on duration of exposure to pharmacotherapy were not available, it is possible that the adult samples—because of dated recommendations to discontinue treatment in adolescence had experienced more years without treatment than the adolescent samples. If so, then it may be that lack of medication coverage in adulthood reduced the overall protective effect of earlier stimulant treatment. Alternatively, enhanced parental monitoring of youths who receive medications may have a preferential effect in adolescents compared with young adults. It may also be that adolescents have not fully passed through the age of risk to develop SUD given that retrospectively derived data from adults indicate that the mean onset of SUD is at 19 years in individuals with ADHD.39 Clearly, more work to disentangle these issues is warranted..."@@
Additional analyses showed that the results could not be accounted for by any single study or by publication bias.
''Conclusion.''
Our results suggest that stimulant therapy in childhood is associated with a reduction in the risk for subsequent drug and alcohol use disorders.

''Attention-Deficit/Hyperactivity Disorder and Early-Onset Substance Use Disorders''
Wilson and Levin
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume 15, Number 5, 2005 Pp. 751–763
@@Review paper - very good coverage of ADHD and SUD@@
__Treating ADHD comorbid with SUD:__
''Atomoxetine.''
Atomoxetine is a promising norepinephrine reuptake inhibitor with little abuse potential and proven effectiveness in treating child and adult ADHD, although no currently published trials address its effectiveness in adolescents with SUD. Some investigators are actively pursuing studies of the effectiveness of atomoxetine during adolescent drug treatment, and results should be available in the next few years. A recent report demonstrated that atomoxetine may be helpful in reducing both ODD, and ADHD symptoms (Newcorn et al. 2005), which may be relevant to adolescents with SUD, ODD and ADHD. Despite the lack of controlled trials, the safety profile of this medication, and its low abuse liability, suggest promise for this medication in the treatment of ADHD with SUD.
''Bupropion''
Bupropion has been suggested to be a firstline medication in this population because of its safety, high tolerability, and limited abuse potential (Wilson and Levin 2001). In one open trial, bupropion has been shown to reduce hyperactivity scores among nondepressed boys in a residential treatment program for delinquent substance abusers (Riggs et al. 1998). However, it is noteworthy that in a laboratory study of adults with marijuana use disorders that bupropion appeared to increase irritability (Haney et al. 2001). This could theoretically be problematic in patients experiencing withdrawal symptoms of irritability secondary to abstaining from marijuana (Haney et al. 1999), but studies specific to adolescents are limited and inconclusive regarding this risk in adolescents. In the Riggs et al. 1998 study, one of the adolescents developed hypomania and irritability, but this participant did have a family history of mood disorder. In another open trial of adult substance abusers, bupropion reduced cocaine use and ADHD symptoms (Levin et al. 1998). Some authors have suggested that bupropion may be more effective for cocaine use disorders that are comorbid with depression or anxiety (Levin et al. 1998; Margolin et al. 1995). In any case, bupropion is currently the only nonstimulant medication with some evidence of efficacy in the treatment of ADHD with SUD in adolescents.
Other nonstimulant medications. The use of ''desipramine'',
despite its proven effectiveness, is
@@limited somewhat because of the tendency of
tricyclic antidepressants to increase the QTc interval.
There are reports of sudden death@@ in
children treated with this medication. Although
all of these deaths were associated with underlying
heart defects, electrocardiograms are currently
recommended at initiation and at each
dose change by the American Academy of Child
and Adolescent Psychiatry. Some clinicians prefer
to use other tricyclic agents, such as ''nortriptiline'',
with fewer side effects and no reported
deaths in children, although there is no empirical
evidence for their effectiveness. Because of
poor judgment and impulsivity in adolescent
substance abusers, and the @@potentially lethal
toxicity of trycyclic antidepressants@@, this medication
may be @@ill-advised in poorly monitored
clinical situations@@.
''Pemoline'' is more effective
than placebo in treating both child and adult
ADHD, but the @@risk of life-threatening liver
toxicity severely limits its use@@ given the availability
of safer, more effective agents.
Alpha-2 adrenergic agents such as ''clonidine'' have been
shown to reduce hyperactivity and impulsivity, but have little, and possibly a negative, affect on attention. The sedating effect of this
medication with active SUD may be a relative
contraindication of this agent.
Potentially ''promising agents'' include ''nodafonil'', ''venlafaxine'',
and ''beta-adrenergic blockers'', although
their effectiveness has not been demonstrated
in controlled trials.
__Stimulants with concurrent ADHD and SUD__
Stimulant pharmacotherapy in the context of SUD.
There are some data to support the treatment
of ADHD to improve substance abuse treatment
response. Two positive double-blind
studies comparing methylphenidate (MPH) to
placebo for the treatment of adult ADHD did
include a small number of substance abusers
(Spencer et al. 1995; Mattes et al. 1984). There
are also promising data suggesting that MPH
(in the sustained-release formulation) is an efficacious
treatment for treatment-seeking cocaine
abusers with ADHD (Levin et al. 1998).
In this study, which used divided daily doses
ranging from 40 to 80 mg/day of sustainedrelease
MPH, both ADHD symptoms and
cocaine use were decreased. (Individual relapse
prevention therapy was also provided.)
Methylphenidate does not appear to have an
effect on cocaine use among adults without
ADHD (Grabowski et al. 1997). The most common
side effects observed were jitteriness and
decreased appetite, but the medication was
tolerated, and discontinuation of treatment
was not required. Additional pilot studies
have also reported that MPH might reduce cocaine
use and ADHD symptoms (Castenada et
al. 2000). However, these are open trials;
double-blind controlled trials are clearly warranted.
No studies were found at the time of
this literature search that utilized the extendedrelease
preparations of methylphenidate. Because
of the possible enhancement of compliance
and extension of behavioral effect, these preparations
may prove to be more useful in reducing
drug use over the entire day.
__Treatment recommendations for ADHD and SUD__
any treatment of
ADHD needs to be individualized. Until more
research is available regarding the safety of
using stimulants in adolescents with ADHD
and SUD, we recommend bupropion and atomoxetine
as first-line treatments. The main
concern with these agents is that they may not
be as effective for ADHD as stimulant medications.
However, the authors believe their lack
of abuse ability makes them a first-line treatment
except in clinical situations where stabilization
of the ADHD is imperative. After a
sufficient trial of atomoxetine and/or bupropion,
if maladaptive ADHD symptoms remain,
a clinician should then consider a
stimulant trial. The safety of such a trial may
be enhanced through careful monitoring of the
prescriptions, frequent visits and urinalyses,
and the use of once-daily medication that can
be monitored by a parent, guardian, or significant
other. In cases with significant depression,
venlafaxine may be indicated. In rare cases, a tricyclic
may be considered, but the safety profile
of a tricyclic must be weighed against the
abuse potential and safety profile of a stimulant.
For some impulsive adolescents, a tricyclic
may be more dangerous and may also be
abused when taken with other medications.

Ken C Winters, Randy D Stinchfield, Elizabeth Opland, Christine Weller, William W Latimer (2000) The effectiveness of the Minnesota Model approach in the treatment of adolescent drug abusers
Addiction 95 (4) , 601–612
The effectiveness of the Minnesota Model approach in the treatment of adolescent drug abusers
• Ken C. Winters,
• Randy D. Stinchfield,
• Elizabeth Opland,
• Christine Weller,
• William W. Latimer
Not a randomised trial as far as I can make out
Abstract
''Aims''.
The treatment outcome of drug-abusing adolescents treated with a 12-Step approach.
''Design''.
The study compares drug use outcome data at 6 and 12 months post-treatment among three groups of adolescents:
#those who completed treatment,
#those who did not and
#those on a waiting list.
Also, among treatment completers, residential and outpatient samples were compared on outcome.
''Setting''.
The treatment site is located in the Minneapolis/St Paul area of Minnesota.
''Participants''.
Two hundred and forty-five drug clinic-referred adolescents (12–18 years old), all of whom met at least one DSM-III-R substance dependence disorder.
One hundred and seventy-nine subjects received either complete or incomplete 12-Step, Minnesota Model treatment and
66 were waiting list subjects.
''NO RANDOMISATION'' as far as it appears
''Measurements''.
In addition to demographics and clinical background variables, measures included treatment involvement, treatment setting and drug use frequency at intake and follow-up.
''Findings''
#Absolute and relative outcome analyses indicated that ''completing treatment was associated with far superior outcome compared to those who did not complete treatment or receive any at all''.
#The percentage of treatment completers who reported either abstinence or a minor lapse for the 12 months following treatment was 53%, compared to 15 and 28% for the incompleter and waiting list groups, respectively.
''Conclusions''.
#Favorable treatment outcome for drug abuse was about two to three times more likely if treatment was completed.
#Also, there were no outcome differences between residential and outpatient groups.
#Alcohol was the most common drug used during the follow-up period, despite cannabis being the preferred drug at intake.

Evaluation of an Internet virtual world chat room
for adolescent smoking cessation
Susan I. Woodruff, Terry L. Conway, Christine C. Edwards, Sean P. Elliott, Jim Crittenden.
Addictive Behaviors 32 (2007) 1769–1786
Good simple study with interesting Rx model - real time motivational therapist acting via internet chat room "BREAthing Room" - as far as authors know the first assessment of Real time counselling on-line in virtual reality.
Mixture of stages of change, nptivational, social learning. psychoeducation and interactive (moderated by the counsellor)
NB Limitations:
#self report outcomes and payments to take part (risk of bias as kids might say "I smoke!" for the money and curiosity...?
#"The groups differed significantly on several baseline smoking variables. Compared to control subjects, intervention participants had started smoking at a younger age, had smoked more cigarettes per day during the previous week, and had smoked more days in the previous week."... so the intervention group were if anything more hard core smokers...
#VEry low participation - high drop out rate: "77 intervention participants averaged about 3 online sessions. About 19% (n=15) never logged on to any session, and 9% (n=7) received all 7 sessions." Despite that @@89% of participants said they would recommend it to another.@@... paradox!
@@Authors suggst it may have been more effective as an ADJUNCT to face to face work... NB [[Longshore et al 2006]] synergistic effect of national media campaign and school based prevention...@@
Abstract (only)
The goal of this longitudinal study was to test an innovative approach to smoking cessation that might be
particularly attractive to adolescent smokers. The study was a participatory research effort between academic and
school partners.
The intervention used an Internet-based, virtual reality world combined with motivational interviewing conducted in real-time by a smoking cessation counselor.
Participants were 136 adolescent smokers recruited from high schools randomized to the intervention or a measurement-only control condition.
Those who participated in the program were significantly more likely than controls to report at the immediate post-intervention assessment
#that they had abstained from smoking during the past week (p≤.01),
#smoked fewer days in the past week (p≤.001),
#smoked fewer cigarettes in the past week (p≤.01), and
#considered themselves a former smoker (p≤.05).
Only the number of times quit was statistically significant at a one-year follow-up assessment (p≤.05).
The lack of longer-term results is discussed, as are methodological challenges in conducting a cluster-randomized
smoking cessation study.

Preventive Effects of Treatment of Disruptive
Behavior Disorder in Middle Childhood on Substance
Use and Delinquent Behavior
MARJO J.S. ZONNEVYLLE-BENDER, PH.D., WALTER MATTHYS, M.D., PH.D.,
NICOLLE M.H. VAN DE WIEL, PH.D., AND JOHN E. LOCHMAN, PH.D.
ABSTRACT
Objective: Disruptive behavior disorder (DBD) is a well-known risk factor for substance abuse and delinquent behavior in
adolescence. Therefore, the long-term preventive effects of treatment of DBD in middle childhood on beginning substance
use and delinquency in early adolescence were investigated. Method: Children with DBD (8Y13 years old) had been
randomly assigned to manualized behavior therapy (Utrecht Coping Power Program; UCPP) or to care as usual (CU) in the
Netherlands. Five years (2003Y2005) after the start of treatment (1996Y1999), substance use and delinquency were
monitored in 61 of the initial 77 adolescents and compared with a matched healthy control group by means of self-report
questionnaires. One-factor analyses of variance and Pearson_s x2 analyses were performed. Results: Differences in
substance use were revealed in favor of the UCPP, with more adolescents in the CU group smoking cigarettes in the last
month (UCPP 17%, CU 42%; x2 = 4.7; p < .03) and more adolescents in the CU group having ever used marijuana (UCPP
13%, CU 35%; x2 = 4.0; p < .045). Moreover, in this respect, the UCPP fit in the range of the matched healthy control group.
Both treatment groups were comparable to the matched healthy control group in delinquent behavior. Conclusions:
Manualized behavior therapy for DBD in middle childhood seems to be more powerful than CU in reducing substance use
in early adolescence. Both treatment conditions show a beneficial long-term preventive effect on delinquency. J. Am. Acad.
Child Adolesc. Psychiatry, 2007;46(1):33Y39. Key Words: disruptive behavior disorder, behavior therapy, substance use,
prevention, delinquency
!The intervention
The Coping Power Program (CPP; Lochman and Wells, 1996) is a preventive program applied to children at risk for delinquency and substance abuse because of their aggressive behavior. The CPP combines a cognitive behavioral intervention for the child with parent management training.
!Inclusion Criteria
They had to meet the criteria for DBD in accordance with the
DSM-IV (American Psychiatric Association, 1994), and they had
to fulfill the additional inclusion criteria: They had to live within
a family structure; outpatient care should be feasible; and their IQ
had to be at least 80 (according to the subtests Vocabulary and
Block design of the WISC-RN, Vandersteene et al., 1986;
Wechsler, 1974). Comorbidity of ADHD was allowed. The
comorbidity was not treated with psychotherapy but with
psychostimulants (methylphenidate). The clinical diagnoses of
DBD and ADHD were based on extensive diagnostic assessment
(psychiatric interviews, psychological assessment, interviews with
parents, and information from the child_s teacher) and were given
by a board-certified child psychiatrist.
!Drug use BEFORE treatment:
Before the start of treatment, there were no significant differences
in substance use between the UCPP and CU groups: 3 of 30 UCPP
patients and 2 of 31 CU patients had ever smoked, and 1 of 30
UCPP patients and 2 of 31 CU patients had ever drunk alcohol. No
one in either group had ever used marijuana. However, patients
were asked retrospectively for their age at first use, and their
retrospective report could have been distorted. Table 1 provides a
description at pretreatment of both groups.
!Outcomes
SUD was reduced in active intervention (UCPP) cf. the CU @ 5 years follow up
No difference in delinquency between UCPP and CU and Healthy controls...

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